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BRITISH FISHES, 2 Vols., with Portraits and Memoirs of Humboldt and Isaac Walton. 





8vo. price 18s. 

" It is a plain, judicious, and practical treatise. It gives the pith of what is known, and of 
what it is requisite to know, and avoids those minute details, which, however appropriate in 
systematic works, fail to sustain their claim to utility in the actual practice of ophthalmic 
art." — Johnson's Medico-Chirurgical Review. 


The following List comprises apart of the Plates, which are finely executed 
by Canton, and carefully coloured. 

Proper and Injurious Modes of examining the Eye distinguished. 

Acute Inflammation of the Conjunctiva. Aphthous or Pustular Inflammation of the 
Conjunctiva. Chronic Aphthous Inflammation of the Conjunctiva. 

Inflammation of the Cornea as seen in Strumous Ophthalmia. Pannus or Vascular 

Granular State of the Conjunctiva of the Upper Lid, with the first effects of its 
pressure upon the Globe. 

Hypopion or Unguis with inflamed Conjunctiva or Cornea. 

Staphyloma of the Cornea. Diffused Staphyloma of the Sclerotic. 

Abscess of the Globe with acute inflammatory Chemosis of the Conjunctiva and dis- 
organised Cornea. 

Abscess of the Globe, with Slough of the Cornea. Fungus Hsematodes as contrasted 
with ditto. Fungus Hsematodes in its earliest stage. 

Incipient Retinitis. Incipient Iritis, and Iritis in a more advanced stage. Prolapsus 
of the Iris. 

Acute diffused Inflammation of the Sclerotic. Haze of the Cornea, with Inflamma- 
tion of the Iris. 

Chronic Sclerotidis. Appearances of Sclerotic and Conjunctival Inflammation con- 

Fungus Hsematodes of the Globe of twelve years standing — ditto at its termination 
after sixteen years — appearance of the Orbit on removal of tumour after Death. 

Melanosis affecting the Globe and Lids. 

Sections of Malignant Diseases, illustrating Hodgson's discovery of the formation of 
Serous Cysts as the origin of Cancerous, Fungoid, and other Diseases. 

Staphyloma Racemosum. Glaucoma — often mistaken for Cataract. 

Purulent Ophthalmia. Inflammatory Chemosis. 

Transparent depression of the Ulcer indicating Ulcer of the Cornea. 

True Pterygium distinguished from Pterygium Pingue. 

Capsulo Lenticular Cataract — Soft Cataract — Central and Opaque Capsular Cataract. 

Progressive Stages of the Operations for Cataract — Operation for Solution— Opera- 
tion for Depression. 

Operation for Artificial Pupil. 

Instruments used in different Operations on the Eye. 


8vo, with Forty-one finished Wood-Engravings, price 12s. cloth boards, 







Bltosttatefc fcy a %rcitz of ©ases anb numerous ^practical Instructions. 
By W. J. LITTLE, M.D. 




&C. &C. 

Contents : — Opinions of Authors, ancient and modern ; "Varieties of Club- 
Foot ; Symptoms ; Anatomy ; Pathology ; Causes ; Distortions from Teething ; 
Contractions from Paralysis and Spasm ; Hysterical Distortions ; Club-Hand ; Con- 
traction from Rheumatism, Abscesses, from long-continued Confinement, from acci- 
dental Rupture of Tendo Achillis ; medical, surgical, and mechanical Treatment of 
Distortions ; Division of Tendons ; Explanation of safety of the Operation; Appen- 
dix of Cases arising from various causes ; Contraction of the Toes ; Contraction of 
the Knee and Hip Joints ; Cure of Ankylosis of the Knee from White-swelling, &c. 


" Dr. Little presents us with a great deal of matter possessing both novelty and 
interest. The drawings interspersed throughout the work, exhibiting the relative 
appearance of the various distortions, both before and after operation, are cleverly 
executed, and form a very valuable addition to his treatise." — British and Foreign 
Medical Review. 

" Dr. Little's treatise contains a most comprehensive and complete description 
of the causes, varieties, and treatment of club-foot. We recommend it to the atten- 
tion of surgeons and heads of families." — Lancet. 

" Dr. Little's treatise will be consulted by every operator, and is unquestionably 
one of the most useful books of the season." — London Medical Gazette. 

" This volume altogether is beyond question the best monograph, foreign or 
English, upon the subject, containing, as it does, not only the opinions and practice 
of continental writers, but the valuable additions made by Dr. Little to this branch 
of science." — The Medical Times. 

" It only remains for us to express our good opinion of the manner in which 
Dr. Little has performed his task. This book will prove a very useful one, and we 
recommend it in strong terms to the profession." — Medico- Chirurgical Revieiv. 


$ __ <& 

Fourth Edition, revised and improved, 8vo, cloth, price 10s. 6d. 





" We know of no book which contains within the same space so much valuable 
information, the result not of fanciful theory, nor of idle hypothesis, but of close 
persevering clinical observation, accompanied with much soundness of judgment, 
and extraordinary clinical tact." — Medico-Chirurgical Review. 

" Our author appears to be of a character which cannot rest content with the 
admission of anomalies, inconsistencies, incongruities, and downright contradictions 
in the axioms and precepts of his profession, for the treatment of disease, and the 
consequent salvation or destruction of human life. He has a taste for the exercise of 
causality and criticism, and a happy tact in the appreciation and description of the 
fatal absurdities involved in the unfortunate ' theories ' that pass in review before 
him. His own exposition of what he conceives to be the true state of the case, in 
every disputable and contested doctrine, is so clear and concise, and the facts and 
arguments stated throughout are all so well hunted up, that we hold him to be a great 
benefactor of the science of medicine. . . His arrangement of all imaginable medi- 
cines under the four heads of stimulants, sedatives, narcotics, and tonics, is one of 
the happy simplifications of classification for which he deserves the eternal gratitude 
of the world of patients and practitioners." — Morning Post. 

" The work of Dr. Billing is a lucid commentary upon the first principles of 
medicine. We strongly recommend not only the perusal, but the study of it to the 
student and young practitioner, and even to the ablest and most experienced, who 
will gain both information and knowledge from reading it." — London Medical and 
Surgical Journal. 

" The quick demand which has been made for a third edition of this work, and 
the highly eulogistic tone with which it has been received by the medical critics, 
naturally entitles it to somewhat of extra-professional notice. . . The style is ex- 
ceedingly simple and clear, describing the various diseases of the human system, 
distinguishing one from the other, and prescribing their remedies with equal per- 
spicuity and intelligent illustration." — Morning Herald. 

" We can imagine no more legitimate mode of producing a useful work than 
this ; and Dr. Billing's opportunities of acquiring experience at the London Hospital, 
combined with the disposition manifested in these expressions [in Preface], entitle 
his observations to great attention. . . That Dr. Billing, an active as well as indepen- 
dent thinker, should find materials for half-a-dozen prefatory reclamations, does in 
no degree so much surprise us as the good humour— little characteristic of reclama- 
tors — with which they are penned. Yet they comprehend important matters : the 
functions of nerves, the reilex principle, the theory of inflammation, the sounds of 
the heart, and the cholera ; concerning all of which matters there has been much ink 
shed." — British and Foreign Medical Review. 

" The third edition of Dr. Billing's ' First Principles of Medicine ' is a very able 
and valuable work ; the fruit, as all scientific works ought to be, of the thoughts and 
inquiries of many years steadily directed to one subject. . . As an example of Dr. 
Billing, we will give an outline of his theory of that important subject inflammation. 
The generally received opinion is, that inflammation arises from increased arterial 
action ; but the Doctor shews there is no action but what is imparted by the heart. 
So far from increased arterial action being the cause of inflammation, it is in reality 
the means or symptom of its cure." — Spectator. 

" Dr Billing enters very largely into an examination of the symptoms indicative 
of the various diseases to which the human frame is internally liable, more especially 


those which affect the heart. The non -professional reader will find in it a mass of 
most useful information conveyed in the plainest language ; and such a reader will 
readily unite with us in pronouncing the absence of professional technicalities in a 
medical work no slight merit." — Sun. 

" The views are liberal, and becoming a medical philosopher. . . The observa- 
tions on secretion and excretion, the growth and disappearance of tumors, &c, are 
well worth perusal : we only regret that space forbids us to do more than refer to 
them. . . The distinctions laid down between narcotics, stimulants, and sedatives, 
will be found of much practical utility to students." — London Medical and Physical 

11 The profession and the public owe an additional debt of gratitude to Dr. Bil- 
ling for his valuable work, the present edition of which is enlarged to twice its 
former size and importance. Dr. Billing, it must be remembered, was the first to 
introduce clinical lectures, to insist on the importance and promote the practice of 
clinical teaching in our medical schools, reducing, as far as it was practicable, the 
science of the healing art to general principles. His long connexion with the Lon- 
don Hospital, and arduous duties there, gave him ample and extensive opportunities 
for acquiring that solid experience which, guided by a correct judgment, has enabled 
him so largely to contribute towards the alleviation of the various maladies incident 
to our nature. We have not space to advert to the many admirable principles laid 
down by Dr. Billing in the work under notice ; we must, however, observe, that 
they are ably, lucidly, and what we consider a great merit in books of instruction, 
plainly written. A summary of all that is known and received as true concerning 
motion, sensation, and organic function, in obedience to the great sympathetic, the 
medulla spinalis, and the sensorium, are related with the brevity and perspicuity of 
one who is master of the subject." — Bell's Weekly Messenger. 

" We have facts in abundance, but it requires the exercise of the highest order of 
intelligence to deduce from them the laws which govern, both in health and in dis- 
ease, the wonderful machine called man. . . Having explained the nature and cause 
of inflammation, Dr. Billing examines the various modes of action of antiphlogistic 
remedies ; and points out, in a very clear and philosophical manner, the principles 
which should guide the practitioner in their application. . . We can strongly recom- 
mend Dr. Billing's ' Principles ' as a code of instructions which should be constantly 
present to the mind of every well-informed and philosophical practitioner of medi- 
cine. " — Lancet. 

" Dr. Billing has entered into the consideration of this subject in the true spirit 
of a philosopher, and he has produced a work which cannot but elevate him consi- 
derably in the estimation of the public and profession. In his introduction he dwells 
upon the importance of the stethoscope to the practical physician ; and we would 
earnestly direct the attention of the faculty to his valuable observations on the 
pathology and treatment of lung-disease."— Monthly Magazine. 

" We should be ungrateful to any gentleman who has made such advances into a 
field of inquiry so unknown and so extensive as that of the nervous system, if we did 
not acknowledge our obligations for what has been produced. . . It is the leading 
virtue of the author never to lose sight of the bedside ; and the numerous points of 
treatment in regard to the exhibition of remedies, distributed throughout the work 
from the first page to the last, would, if extracted, alone form a catalogue worthy of 
being committed to memory." — London Medical Gazette. 

"Of these, Dr. Billing's ' First Principles of Medicine ' is the most comprehen- 
sive and important. It presents a combination, as valuable as it is rare, of practical 
knowledge and scientific principles. . . In this publication Dr. Billing has conferred 
upon the profession as great a service as he did in originating clinical lectures in our 
hospitals, the honour of the introduction of which belongs exclusivelv to him. Two 
such incidents in the life of a medical man are sufficient to secure to his name a 
lasting reputation." — Monthly Chronicle. 

London : S. HIGHLEY, 32 Fleet Street. 
Edinburgh, Maclachlan and Stewaiit ; Dublin, Fannin and Co. 






i3 Great Now Street, Fetter Lane. 

OCtyC-ZS z^-z*~ 














HtcbtsrU anli (mprobeU. 











CfjtS 'Folume i& tttUicatttl 



Tu, qui natales antiquo sanguine claros 

Ingenii decoras nobilitate nova, 
Accipe non magna turgentem mole libellum, 

Et mea mansuete quantulacunque lege. 
Publicus his postquam favor adfuit, acrius audens 

Spem de se tandem ccepit habere liber ; 
Nee satis esse put at : si Tu dignabere laude, 

Hoc saltern titulo tutior esse cupit. 




Though it may be thought that the third edition of a 
book requires no advertisement, I consider it quite neces- 
sary to explain some circumstances connected with this 
work. Feeling that no author has been more indebted 
to the indulgence of the public press for kind criticism, 
I have endeavoured to profit by the hints given me in 
every respect but one. The first edition was sent forth 
to take its chance in the world without herald of preface 
or advertisement, unadorned by dedication, and unaccom- 
panied by any table of contents : my original reasons for 
the last omission remain unshaken ; and I have therefore 
merely given, for the convenience of students, a few pages 
so prepared that they may make an index for their own 
use, by putting down, as they go through the work, the 
position in which subjects occur in dhTerent parts of it; as 
I have done with respect to " arterial action," " ulceration," 

&c. &c. 

I found that the former editions were more pleasing to 
fully educated medical men and men of experience than to 
the tyro. This was not my original intention ; and I have 


bined advantageously with sedatives, with stimulants, or 
with narcotics ; how stimulants are tonic ; how sedatives are 
tonic ; how narcotics are tonic ; and, though not a homce- 
opathist, how emetics stop vomiting, and purgatives diar- 
rhoea. I have shewn how every medical man has his hobby 
to carry him to the same point, which, though he thinks it 
very different from his neighbour's, is as like it as one 
four-legged jade is to another ; how one man thinks he has 
made a discovery that he can cure cholera with sugar of 
lead, and that there is nothing equal to it ; whilst tartar- 
emetic, calomel, Epsom salts, or Glauber salts, or common 
salt, or mustard, or lemonade, or vinegar and water, &c. &c, 
will do the same thing; though none of them more quickly 
carry off the vomiting and purging than two of these hob- 
bies in double harness — tartar-emetic with some neutral 
salt, I care little which. 

An anonymous writer once advanced against this work, 
that I differed from J. Hunter in the theory of inflamma- 
tion, — as if he were " the law and the gospel." It may be 
seen that I differ not only from J. Hunter, but from his 

minus, takes place on every act of volition ; in other words, that there is an 
electric communication between the brain and the tips of the fingers, whether 
in playing the pianoforte, or making the passes or actions of animal magne- 
tism ; and every one of these actions is a succession of weak electric shocks, 
not individually perceptible, but by continuation producing an impression or 
result ; as an electric jar may be charged by a weak electric machine, though 
no sparks be visible. The person who makes the passes produces a succes- 
sion of transmissions of electricity, which alters the electric stale of the brain 
of the person magnetised, who is in a state of quiescence, and whose nervous 
system will be more susceptible if out of health or inclined to coma, indepen- 
dent of the very various degrees of susceptibility of the nervous system of 
persons even in health. 


talented successors, Bichat, Sir A. Cooper, W. Lawrence, 
and others, in theory, on physiological and pathological 
principles, though little in therapeutics. On the subject 
of the division and classification of remedies, on the cause 
of the sounds of the heart, on the proximate cause of in- 
flammation, on morbid sensibility, &c, I feel confident of 
obtaining the future suffrages of the profession. On the 
essential points of practice in the treatment of inflamma- 
tion, I agree of course with men of such experience as Sir 
A. Cooper and Lawrence. It may be asked, then, what 
does it signify wherein we differ ? It is, in my opinion, 
of great consequence to correct erroneous theories, and 
thereby enable students to arrive sooner at well-founded 
principles of practice. 

Although this work consists rather of general pathology 
than what is called the practice of medicine, it will be 
found to contain the essentials of the treatment of disease. 
The greatest difficulties have arisen from the loose way in 
which remedies have been arranged and classified : I have 
endeavoured to remove these difficulties by the division 
into stimulants, sedatives, narcotics, and tonics; and by 
shewing how these are to be combined with each other, so 
as to afford a guide to clinical practice. 

We sometimes find persons doubting the efficacy of 
valuable remedies from not knowing how to apply them ; 
for instance, bark, sarsaparilla, dulcamara, logwood, car- 
bonate of iron, arsenic, conium, digitalis, elaterium, hydro- 
cyanic acid, and blisters ; each of these has at one time or 
other been said to be either inert or injurious, from misap- 
plication, though they are powerful and efficacious reme- 


dies. We every day meet with old men who from preju- 
dice have scarcely ever used some one or other of these 
substances; though others, placed in an extensive field of 
practice, such as our hospitals, use them daily with advan- 
tage : there are even persons who have been thirty or forty 
years in tolerably extensive practice who have not made 
use of a lancet so many times. 

In going round the wards of an hospital a pupil might 
remark to the physician at one bed, What a small dose, and 
at the very next, perhaps, What a large dose, you have 
given; large and small being both incorrect terms when 
the force applied is properly adapted to the quantity of 
disease and state of constitution. In practice there should 
be no such thing as boldness or timidity : boldness is an 
ignorance (for we must not suppose a recklessness) of the 
harm which too strong means may do a fellow-creature ; 
and timidity is an ignorance of the efficient means which 
remedies afford of relieving human suffering. 

In this edition I have added many cases, in illustration of 
principles laid down, as they are equivalent to diagrams in 
geometry. A person who has studied geometry can under- 
stand the proof of a proposition in general terms without a 
diagram — but not so a beginner ; and a beginner in medi- 
cine requires a reference to cases, to render some general 
principles intelligible. 




I was originally led to publish this treatise by a recollec- 
tion of the difficulties I had met with in the study of my 
profession, and by the hope that I might aid in removing 
them from the path of others. 

Upon commencing the study of medicine and surgery, 
after having become acquainted with the more precise phy- 
sical sciences in the University, I was appalled to find it a 
complete chaos. Our family physician, really a man of 
great talent, and one of our professors, disheartened me by 
his answers. I inquired, " What is fever?" — Answer, of 
course, Cullen's definition. " But what produces it ? " — 
" Sometimes one thing, sometimes another: excessive cold 
or heat, or the effluvia from a person who has fever." " But 
what is the cause of the phenomena in the body ?" — " Spas- 
modic contraction of the extreme vessels." I could under- 
stand that cold might contract the extreme vessels, but I 
had been taught by the professor of chemistry that caloric 
expanded every thing. And, again, I did not see how 
effluvia produced spasm, nor how the spasm, even if it 
were produced, could make the skin extremely hot as well 
as cold. I was advised to read Cullen, and did so ; but 
without finding the information I sought. Again I asked, 
" When you give a dose of rhubarb or castor oil to stop a 
diarrhoea of several days' standing, how does it effect this 
object?" — " By clearing away the peccant matter." " But 
would not the diarrhoea scour away this peccant matter 
itself ? " — " Not so well." This did not satisfy me. 



dies. We every day meet with old men who from preju- 
dice have scarcely ever used some one or other of these 
substances; though others, placed in an extensive field of 
practice, such as our hospitals, use them daily with advan- 
tage : there are even persons who have been thirty or forty 
years in tolerably extensive practice who have not made 
use of a lancet so many times. 

In going round the wards of an hospital a pupil might 
remark to the physician at one bed, What a small dose, and 
at the very next, perhaps, What a large dose, you have 
given ; large and small being both incorrect terms when 
the force applied is properly adapted to the quantity of 
disease and state of constitution. In practice there should 
be no such thing as boldness or timidity : boldness is an 
ignorance (for we must not suppose a recklessness) of the 
harm which too strong means may do a fellow-creature ; 
and timidity is an ignorance of the efficient means which 
remedies afford of relieving human suffering. 

In this edition I have added many cases, in illustration of 
principles laid down, as they are equivalent to diagrams in 
geometry. A person who has studied geometry can under- 
stand the proof of a proposition in general terms without a 
diagram — but not so a beginner; and a beginner in medi- 
cine requires a reference to cases, to render some general 
principles intelligible. 




I was originally led to publish this treatise by a recollec- 
tion of the difficulties I had met with in the study of my 
profession, and by the hope that I might aid in removing 
them from the path of others. 

Upon commencing the study of medicine and surgery, 
after having become acquainted with the more precise phy- 
sical sciences in the University, I was appalled to find it a 
complete chaos. Our family physician, really a man of 
great talent, and one of our professors, disheartened me by 
his answers. I inquired, " What is fever?" — Answer, of 
course, Cullen's definition. " But what produces it ? " — 
" Sometimes one thing, sometimes another: excessive cold 
or heat, or the effluvia from a person who has fever." " But 
what is the cause of the phenomena in the body ?" — " Spas- 
modic contraction of the extreme vessels." I could under- 
stand that cold might contract the extreme vessels, but I 
had been taught by the professor of chemistry that caloric 
expanded every thing. And, again, I did not see how 
effluvia produced spasm, nor how the spasm, even if it 
were produced, could make the skin extremely hot as well 
as cold. I was advised to read Cullen, and did so ; but 
without finding the information I sought. Again I asked, 
" When you give a dose of rhubarb or castor oil to stop a 
diarrhoea of several days' standing, how does it effect this 
object?" — " By clearing away the peccant matter." " But 
would not the diarrhoea scour away this peccant matter 
itself?" — " Not so well." This did not satisfy me. 



Neither could the surgeon clear up these points : " for 
his part, he did not pretend to understand physic." I 
" walked" the hospital at his elbow as dresser, and in- 
quired, " Why do you apply a cold lotion to that inflam- 
mation?" — "To moderate the action [ of the vessels?" — 
"Inflammation, then, is over-action of the vessels?" — 
"Yes." "Why do you apply that astringent (goulard 
or nitrate of silver) to that other inflammation?" — "To 
diminish the action of the vessels." Now, the action of 
the vessels being contraction, my logic did not enable me 
to comprehend him ; so, after asking why he put a cold 
lotion or poultice on one inflamed part, and a warm poul- 
tice or fomentation on another, and being told that I should 
find out by experience, I resolved on attempting to find 
out for myself. 

I accordingly set seriously to work, and endeavoured 
to draw up a little code of general principles for my own 
use, as I could find nothing of the kind existing. The 
so-called systems of Cullen, Brown, Broussais, Rasori, &c, 
seemed mere individual opinions, totally differing from 
each other; and which was I to follow? Each of their 
originators appeared confident in himself, and despised his 
adversary ; while their followers almost came to blows, 
arguing as much for victory as the love of truth. I 
visited the different schools : the students of each hinted, 
if they did not assert, that the other sects killed their 
patients ; but I found that, provided the physician of each 
school was a man of talent and experience, the mortality 
was fairly balanced. I therefore concluded that, on in- 
vestigation, some true general principles would be found 
to exist by which the apparent inconsistencies of correct 
practice might be reconciled, and the contest between 
such systems as were essentially at variance be decided. 
But though innumerable volumes of cases, and intermin- 
able heaps of insulated precedents, were to be met with, 
no tieat^e upon first principles had appeared. 

After twenty years of intense application to clinical 


practice, as student, assistant, and professor, I found the 
same acknowledged necessity for reducing the conflicting 
systems of medicine to general principles ; and I therefore 
ventured to publish the result of my own labours, com- 
pressed into 130 pages.* 

The subject of clinical lectures is closely connected 
with the attempt to reduce the science to general prin- 
ciples. In medical publications much just censure has 
been expressed of the neglect of clinical instruction, and 
of the omission on the part of hospital physicians and sur- 
geons to render their experience available to the profession 
in general, and consequently to the public. In 1822 I had 
the honour to be elected Physician of the London Hospi- 
tal,-]- at which time no clinical lectures were given in Lon- 
don : in the same year, however, I commenced this impor- 
tant branch of medical education, not merely instructing 
the pupils in the wards and theatre, but attending and 
explaining post-mortem examinations. This course I pur- 
sued, at a great sacrifice of time and some of health, for 

* The trouble it cost in condensation makes me pleased whenever the 
term "little" is applied to the work ; and I cannot deny myself the satis- 
faction of transcribing the words of Professor Stromeyer, of Hanover : ** Dr. 
Billing's book is a very clever little pathologia generalis ; his views certainly 
go beyond those of most pathologists, by his taking the nervous system into 
consideration. Upon the whole, I think it as much adapted for fully edu- 
cated medical men as for students. Books like this are very rare ; almost 
every writer strives, whatever few original ideas he has, to bury them in a 
mountain of generally known matter ; whilst Dr. B. gives us a very intellec- 
tual (ffeistreich) view of his peculiarities." I must acknowledge also that I 
derived much satisfaction from the favourable notices of the medical re- 
viewers ; as their testimony gave me more confidence in the approbation ex- 
pressed by private friends. 

t The London Hospital, incorporated by royal charter in 1795, besides 
between nine and ten thousand cases per annum of diseases and injuries 
treated by the physicians and surgeons as out-patients, contains 320 beds, 
always filled with fit subjects of clinical study ; the surgical accidents average 
fifty per week. Several foreign hospitals have twice and three times this 
number of beds ; but they include persons disabled by old age, imbecility of 
mind, malformation, &c. — such as are taken care of in our workhouses and 
asylums of various denominations. 


six or seven years ; when the rising members who had been 
my clinical secretaries, — Drs. Macbraire and W. J. Little 
(the latter now Professor of Comparative Anatomy, alum- 
nus dignissimus of Miiller and Grant), Messrs. Hamilton, 
Adams, Curling, &c, — being able to relieve me, I con- 
tinued only the lectures, instructions in the wards, and 
once a week an anatomical demonstration, illustrating cases 
by recently obtained specimens, or by those in the exten- 
sive collection of pathological anatomy in the museum. In 
tins mode I persevered up to the present session (1836), 
when, from being appointed to the University of London, 
it became impossible for me to continue it. I have of late 
years had the satisfaction of finding the example very ge- 
nerally followed in the metropolis, besides that of witness- 
ing the success of the school in which it was first regularly 

The medical officers of the London Hospital, I must 
also observe, were among the first who were mainly 
instrumental in introducing auscultation ; and I am sur- 
prised that it is not yet by any means generally adopted. 
It is a source of real regret to me that so few medical men 
have taken the trouble, or known how, to avail themselves 
of this invaluable and indispensable method of detecting, 
so as to combat, the most deadly diseases of the chest. 
On this score Dr. T. Davies gained a well-earned cele- 
brity ; he not merely gave lectures to pupils, but col- 
lected the members of the profession at the east end of 
the town, at his own house, and instructed them in this 
almost new sense of perception. From the time he be- 
came one of the medical officers of the London Hospital, 
in 1829, I derived great assistance from him in the 
clinical department, in the instruction of those young 
gentlemen who had the good sense to avail themselves 
of the opportunities afforded them of learning ausculta- 
tion and the use of the stethoscope. One cannot be 
much surprised that the multitude are slow in adopting 
what in some instances has been treated with neglect and 



in others has met with decided opposition, by men in high 
reputation and practice. As to the stethoscope, I wish it 
were understood that it is not absolutely necessary, except 
from motives of delicacy; as the apparent difficulty of using 
it deters some persons from commencing auscultation, and 
has given occasionally an opportunity for opponents to use 
a tremendous substitute for reasoning — ridicule ! It is 
disagreeable to apply the ear to the chest if the patient, 
as occurs sometimes in charitable institutions, be not 
clean ; and if the patient be a female, it is objectionable 
for other reasons : hence the artificial elongation of the 
meatus auditorius externus, called stethoscope, becomes 
eligible, though no better than the naked ear to judge by. 
I am in the habit of using a very simple one, which is 
merely Laennec's abridged, instead of being complicated, 
as it has been by other improvers of his instrument : it is 
rounded and cut away in the middle to make it light and 
convenient ; the flat end being turned to the chest answers 
the purpose of the obturator; and it is only four inches 
long, which is sufficient for the purpose as to stethoscoper 
and stethoscoped, and may be obtained from any wood- 
turner for a few pence. 

Section of the Stethoscope. 

One great difficulty in the way of learners of ausculta- 
tion is their attempting to begin on patients :■ this is like 
trying to study morbid anatomy before acquiring a know- 


siologically and pathologically, valvular sound is the one 
we have to depend upon; for granting, for argument's 
sake even, that any other exists as a normal accompani- 
ment, it has no more to do with the sound, than the 
drone of a bagpipe has to do with the tune. In his last 
appendix, Dr. Hope began to allow that the first sound 
may be " possibly partly valvular," but still adheres to 
the " bruit musculaire." 

According to the report of the London Committee of 
the British Association, the subject seemed to be in the 
position agreeing with the vulgar notion of a " suit in 
Chancery" ("Med. Gaz.," Dec. 10, 1836). 

With respect to the assertion of a celebrated experi- 
menting physiologist, that the sound is produced by the 
heart coming pit-a-pat against the parietes of the chest, 
it is only necessary to refer to Mr. Bryan's beautifully 
ingenious experiment (" Lancet," Feb. 8, 1834; also Dec. 
26, 1835, and Feb. 21, 1836); by which he proved that 
the heart never quits the anterior, but remains in apposi- 
tion during both systole and diastole. 

In giving the above explanation to my class, I was in 
the habit of exemplifying how the sound was produced, by 
a strip of paper two or three inches long, and half an inch 
wide, suddenly stretched — the sound of which was heard 
all over the theatre. Dr. Hope subsequently mentioned, 
in his Appendix, 1835, his having employed a piece of 
tape for a similar purpose. 


Mr. Bryan published the same theory (" Lancet," Jan. 
1833) ; but when he became acquainted with my priority, 
he very candidly wrote an acknowledgment, in a critique 
on the Report of the Dublin Committee of the British As- 
sociation (" Lancet," Dec. 26, 1835, and Feb. 21, 1836). 
In our science, from insufficiency of data, and being 
often obliged to found our arguments on analogies, it is 
difficult to avoid falling into errors of non causa, and rea- 


soiling in a circle. I therefore claim indulgence, and 
entreat some of my highly gifted brethren to improve on 
my suggestions. 

The following additional matter on the causes of the sounds of the heart 
was published by me in the " Medical Gazette," April 1840. 

* * * * ]yjy object is to prove that the physiological sounds of the 
heart are caused by the valves, and the valves only. The question is still 
sub judice ; at least, I have met with no public acknowledgment of the 
truth of my proposition, published in 1832, that the normal sounds of 
the heart are produced by, and depend upon, the tension of the valves. 

The moment I read Laennec's assertion, that the second sound was 
caused by the auricles, I perceived that it was erroneous, as being incon- 
sistent with the successive actions of the heart, acknowledged by phy- 
siologists from the time of Haller, and fully confirmed by experiments 
on animals, — viz., that the auricles contract first ; then, following con- 
tinuously without any interval, the ventricles ; and that subsequently 
there is a period of relaxation, or cessation of action, in each part 
during the diastole * between each systole. I was thus satisfied (from 
the repose of the muscle) of the impossibility of the auricles having any 
thing to do with the second sound, there being no action of either 
auricles or ventricles going on at the moment, for it was the time of 
relaxation of both. 

Dr. Hope, in his first edition, p. 49, endeavoured to prove that this 
sound was produced by the " ventricular diastole," and " the blood 
shooting with instantaneous velocity from the auricles into the ventri- 
cles ;" although, as he set out with acknowledging that the second 
sound takes place at the moment that the auricle is relaxed, the blood 
at that time could be only flowing into the ventricle gently from the 
veins through the auricles, as it always does at that time ; for the ven- 
tricles are partly filled in this way, before the auricles (which are never 
empty) inject the blood into them, so as to stimulate them. 

It was evident to me that there was no cause in existence at the 
moment to produce the sound, except the tympanic tension of the ven- 
triculo-arterial (sigmoid) valves ; or, in other words, that the sound 

* During the diastole the muscles are flabby, and yield to the pressure of a probe, 
whilst during systole they are felt to resist or rather repulse it. The heart being a 
forcing pump, it is merely necessary to apply one hand over it, and the other to the 
pulse, to be satisfied that the beat of the heart (" impulsion ") depends upon the firm 
bulging of the muscles in 9Vstole. 


butes the sudden nature of that sound to the rapid and vehement (as if 
relaxation could be vehement) diastole of the ventricle ; and its abrupt 
termination (" abruptam" in italics) to the instantaneous impediment 
which the sigmoid valves offer to that motion of blood to which alone 
he refers sound. Thus the only allusion he makes to the valves is, 
not as producing, but as cutting short the sound; and so far from 
considering the valves to be the cause of sound, he is evidently puz- 
zled (as we may infer from the expression " fatendum est ") to 
account for the sound ceasing when it does, " though the blood con- 
tinues to flow into the ventricles after the sound has stopped," which 
my explanation of valvular sound renders perfectly clear : the passage 
shews that he looked only to the flow of the blood, and not the valves, 
as the cause of the sound. In fact, so far from originating the opinion 
of the sound depending on the valves, he does not advance that as his 
opinion ; and in this thesis there is no originality, but a professional 
compilation and adoption of the opinion of others — Hope, "Wil- 
liams, &c. 

The following is the passage from Dr. Elliott's thesis : — " Nobis igitur 
(me judice) concludendum est, sanguinem a ventriculis agitatum et in 
arterias immissum, primum sonum cordis efficere : secundumque a san- 
guine pendere in ventriculos, dum horum fit diastole, ex auriculis influ- 
ente. Hoc plane confirmatur a phsenomenis quae in vitiis valvularum 
cordis observantur. Naturam soni secundi subitam et abruptam oriri 
credo a diastole ventriculorum tam repente et vehementer inchoata ut 
sanguis vi magna auricularum parietes transcurrat : nee non ab im- 
pedimenta quod in corpore sano fere instanter valvulse prsestant sig- 
moideee sanguini, qui in ventriculos, dum horum fit diastole, ex arteriis 
vult refluere. Post sonum secundum quidem fatendum est adhuc plus 
sanguinis ventriculos inire : hie autem, ut annotat Hope, ventriculorum 
parietes (jam multo fiuido distentos nee ultra ab illo fricatos) haud 
verrit, sed cum sanguine jam illic congesto, sese in silentio commiscet 
nee aliquid interea soni ab auriculis editur, quippe quae sanguinem 
quern impellunt accurate usque sequuntur. Motum igitur sanguinis, 
tam a diastole quam a systole ventriculorum effectum, sonorum cordis 
prsecipuam esse causam credendum est: quod ab observationibus qui- 
busdam Doctorum Bertin, Williams, et Hope, singulari in modo con- 

The London Committee of the British Association (including Dr. 
C. J. B. Williams), appointed to investigate and report upon the sub- 
ject, appear to agree with me as to the second sound, but make the 
unphilosophical addition of bruit musculaire to the true cause of the 
first. (See "Med. Gazette," Dec. 10, 1836, and Dec. 2, 1837.) I say 
they appear to agree with me, so far as acknowledging the valves to 
be the cause of sound ; but they do not seem to adopt the true prin- 


ciple, which is, that it is the tympanic tension which produces the 
sound. I judge from the expression in the report, that "it is impos- 
sible that the auriculo-ventricular valves should close with ajlap, in the 
same way as the sigmoid valves." They speak as if the surfaces of 
the valves flapping together produced the sound, like the click of a 
solid valve ; and moreover, in conformity with this, in the republication 
of the same opinion in the Cyclopaedia of Anatomy and Physiology, 
(article Heart, p. 616,) edited by Dr. Todd, one of the committee, my 
statement is misrepresented, by saying that the first sound is referred 
by me to the rapid approximation of the auriculo-ventricular valves ; 
than which nothing is farther from my opinion, which is, that both first 
and second physiological sounds depend solely on valvular tension. 


The first step towards treating disease successfully 
is to ascertain, as far as possible, the nature of the 
functional or structural alteration which has taken 
place in the tissues of the part affected : in default 
of this knowledge, which is sometimes unattainable, 
we can only depend upon analogies, drawn from 
what we know to be the fact in other cases, and 
from physiology, which is a careful observation of 
the 'phenomena resulting from the functions of the 
different parts in health. 

An accurate knowledge of the functions in their 
healthy state is the more necessary, because con- 
siderable * deviations from the ordinary routine 
occur without disease ; and as they are frequently 
much disturbed without any discoverable alteration 
in the structure of the organs having taken place, 
morbid anatomy alone will not be sufficient to 
elucidate all causes of disease ;f whilst, on the 

* In such instances, an undue interference with nature, by 
purgatives, emenagogues, &c, might do more harm than the 

f This is more especially the case in diseases of the nervous 
system, and points out the value of remedies which exert an in- 
fluence on deranged function, without the operation of any agent 
capable of effecting depletion of the vessels, or of changing 


other hand, it is necessary to be aware that a 
considerably diseased change of structure may 
exist with little or no interruption of function * 
The modes by which students may attain a 
knowledge of the nature of disease, after learning 
physiology, or the nature of healthy functions 
(which is attainable from lectures), are, accurate 
observation of the diseases which take place in 
external parts as they are submitted to our senses 
in clinical surgery, and in the functions of inter- 
nal parts as met with in clinical medicine; and 
morbid anatomy, the examination of what is the 
degree and nature of alteration which has taken 
place in the structure of the seat of the disease. 

The object of lectures is to convey to the stu- 
dent, in a condensed manner, that knowledge in 
abstract which will enable him to understand what 
he sees at the bed-side, and the observations of the 
clinical professor; without which clinical instruc- 
tion, all that the memory may be charged with 
from books or lectures, is but vanity. 

Without entering into minute anatomy, it may 
be necessary, before proceeding any farther, to 
give a general idea of the apparatus which sup- 
ports the life of man, consisting of the stomach 
and intestinal canal, called the prim,e vle, the 
absorbent vessels, the heart and blood-vessels, 
and the nerves. 

The heart is divided by a partition, each side 

* This consideration will prevent disease being overlooked in 
an organ (as the liver, kidney, &c.) whose function is, or seems 
unimpaired, when indirect symptoms and morbid sympathies' 


containing a certain quantity of blood, more or 
less of which is squeezed out at each beat or 
contraction ; the blood from the left side is sent 
through the trunk and branches of the arteries, to 
nourish the different parts of the body ; the over- 
plus, and what is spoiled by use, being returned 
through the veins to the right side, which sends it 
by arteries into the lungs to be purified (in addi- 
tion to changes effected by the liver, kidneys, &c), 
whence it is returned by veins to the left side 
again, thus constituting what is called the circu- 
lation. This is the nature of the circulation with 
which the individual born begins life, before food 
has been taken. 

Subsequently, the process of nutrition is thus 
carried on: the food swallowed is digested by the 
action of the gastric juice in the stomach; that 
is, it is converted into a grey pulpy mass, called 
chyme, which passes on into the intestines, where 
it is mixed with the bile. The use of the bile is 
to unite with and separate the feculent parts, as 
white of egg is used to clear wine. Now, if a 
pulpy mass be allowed to stand in a vessel, the 
solid parts will settle to the bottom ; but if rolled 
about in the hands, or in the manner effected by 
the peristaltic motion of the intestines, the more 
solid parts are kept in the middle, whilst the sur- 
face of the mass is the moistest ; and thus a 
whitish liquid, called chyle, which was disengaged 
when the bile united with the feculent matter, and 
which caused the chyme to appear grey, and con- 
stitutes the new nourishment, is kept next the 
coats of the intestines, where it is taken in by the 


tubes called absorbent vessels ; and these absor- 
bents, on account of the white chyle seen through 
them, are called lacteal (milky). 

The lacteal absorbents conduct this fresh supply 
of nourishment to make new blood ; they deliver it 
first into the veins, near the heart, where it is 
mixed with the old dark-coloured blood, which 
has been circulated, and is on its return to the 
right side of the heart ; from whence this mixture 
is sent through the lungs, to be purified, where it 
becomes bright scarlet, and is then returned to the 
left side of the heart, which sends it through the 
arteries all over the frame, to supply its demands. 

All the business of constant support and re- 
newal of parts, and supply of secretions, as the 
growth or repair of bone, muscle, membrane, and 
other structures, the formation of bile, saliva, mu- 
cus, and other secretions, is carried on by the ex- 
treme minute branches of the blood-vessels ; and 
whilst they preserve their proper size and tone, all 
goes on well ; when their action is deranged, dis- 
ease commences, often prefaced by pain or other 
disorder of the nerves. The ultimate minute 
branches of the arteries, from their fineness, are 
called capillary (from capillus, a hair). 

The colour of the blood is caused by red par- 
ticles diffused through a transparent fluid, liquor 
sanguinis, composed of serum holding fibrine in 
solution. When blood is first drawn, the red par- 
ticles may be seen floating about by the means of 
a microscope ; but when it stands, they settle down 
to the bottom, in the fibrinous cake or clot (called 
cruor or crassamentum) which forms by coagulation. 


Some capillaries are too small to admit many 
of the red particles, unless when they are enlarged 
by inflammation, as in the eye, which, when in- 
flamed, changes from white to red ; besides that, 
even the red capillaries are so minute, that they 
are not visible individually to the naked eye till 
enlarged by inflammation. 

The body is nourished by the arteries deposit- 
ing in appropriate parts the various constituents 
of the blood, which is sent through them by the 
heart. In this way muscles, bones, membranes, 
&c, grow and are nourished; for the blood con- 
tains the constituents of each : fibrine, &c, for 
instance, to make muscles ; lime, &c, for the 
bones ; albuminous and watery fluid for the forma- 
tion of membranes, and to supply the secretions 
and exhalations which are necessary to lubricate 
the mucous and serous membranes. 

Though a consideration of the phenomena re- 
sulting from these depositions will assist us in our 
explanation of disease, we cannot exactly ascertain 
how the depositions themselves are originated. Do 
arteries build up a bone merely by the addition 
of homogeneous matter ? And, are the secretions 
and exhalations modified by the calibre of the 
minute branches admitting only the vapoury parts 
to the surface of the serous membranes and of the 
skin, whilst they permit the transparent fluid parts 
of the blood to pass to the mucous surfaces, and 
keep back the red globules ? This mechanical 
explanation might suffice, in part, in the instances 
adduced ; but when we come to the nutrition and 
renewal of muscle, and the formation of peculiar 


secretions, we must look for some still uncompre- 
hended agency, which modifies the materials con- 
veyed by the arteries whilst they are depositing : 
even with respect to the deposition of bone, this 
agency is required to solidify the new particles 
which are fluid in the blood. This power can be 
no other than chemical : the processes, when ex- 
amined, will be found to be chemical precipitations, 
by which new matter is deposited, and decomposition, 
by which old matter is separated, and then carried 
off by absorbents ; and thus the support of the 
frame in health, and the changes of disease, pro- 
ceed. In this investigation we may advance a 
considerable way, though we cannot come to the 
knowledge of the ultimate principle on which 
organic life depends, or we should be able to con- 
struct a man. As an instance how far we can go, 
we can analyse bone, and we may explain how 
bony matter is deposited from the blood by preci- 
pitation ; and we know that the shape depends on 
the periosteum, or membranous mould in which it 
is cast : but here we stop ; we cannot discover 
how, in the minute embryo in the womb, the 
membranes were first determined in their shapes ; 
we here arrive at the confines of our knowledge ; 
and must confess an infinitely wise First Cause, 
who does not permit us to know more than the 
phenomena by which we can judge how, in many 
instances, to avail ourselves of the means to regu- 
late the complicated apparatus which He has en- 
dowed with life. 

The deposition of bone is a combination of 
chemical precipitation and crystallisation, modified 


by vital actions ; as, for instance, when there is 
periosteal membrane, we see that it keeps up a 
vital state of bone, whether in the bone of a leg or 
a tooth ; when there is no membrane attached, as 
in the enamel of the tooth, crystallisation, with 
the temporary membrane which forms the mould, 
decides the form of aggregation ; in case of fracture 
of a bone, the surrounding parts decide the form 
of the callus which reunites it. Whilst bone is 
growing (as shewn by the common experiment of 
feeding young animals with madder, so as to pro- 
duce variegated deposits), there is a change as to 
disposition of the bony matter going on ; but there 
is no reason to suppose that the substance of a 
healthy sound bone of an adult is changing, any 
more than of a tooth, or the wall of a castle, 
though there are preparations ready to repair a 
breach, if made. 

During health the capillary arteries go on with 
their work of nutrition and secretion, the muscles 
are fed, the mucous surfaces are lubricated just 
enough to prevent any sensation from the sub- 
stances which pass along them, the serous sur- 
faces are made sufficiently moist to slide upon 
each other without sensation, and the skin is 
kept soft by an insensible vapour. All this time 
there is another process going forward also, which 
is the removal of superfluous matter by the ab- 
sorbents : if it were not for these, there would be 
inconvenient accumulation of what is deposited by 
the arteries ; the serous cavities, as that of the 
abdomen, for instance, would become dropsical, if 
the capillary arteries went on moistening the inter- 


nal surface, and there were no absorbents to carry 
off the superfluous moisture. Thus we see that 
absorbents take up the nourishment from the 
food to supply the wants of the system ; they also 
take up the particles which become superfluous, 
according as the arteries deposit fresh matter ; and 
these absorbents, like the lacteals, mix their con- 
tents with the old blood to be repurified. The 
deposit, or precipitation, of solid matter by the ar- 
teries is not difficult to be understood ; and we can, 
by a reference to chemical action, account for the 
removal also of solids ; for solids become fluid (or 
gaseous) by what is called spontaneous decomposi- 
tion, and thus removable by absorbents. Now, whilst 
bone is healthy, it is protected by its membranes 
from the action of solvents ; but when inflamma- 
tion surrounds it, there is an extravasation of 
serous fluid in contact with it, which helps to dis- 
solve it, and when dissolved, the absorbents will 
carry away the solution. 

The removal of bone by the pressure oi tumours, 
aneurysms, abscess, &c, as well as the channels 
left in exostoses for the vessels which traverse them, 
is effected by pressure against vessels, not against 
bone. The pressure of a tumour causes death of 
the part of bone, by compressing its vessels, and so 
stopping the supply of nourishment; the bone, 
when dead, becomes decomposed, and is carried 
off by absorbents. As to the channel in the 
growth of an exostosis, or in the natural growth 
of the bones of an infant's head, it is merely the 
deposit of bony matter by the side of those vessels 
which previously existed. Thus so soft a body as 


the brain of a young person causes the hard skull 
to grow larger. 

Arteries are endowed with the power of con- 
tracting on their contents, so as to continue full 
even when a considerable quantity of blood has 
been lost either by haemorrhage or artificial means. 
This contraction is the action of arteries, and is 
distinct from, and opposed to, the contraction and 
action of the heart. This point it is necessary to 
understand clearly in speaking of the phenomena 
of disease. 

The contraction of the heart is muscular — of 
the arteries elastic. The heart contracts and re- 
STANT contractile pressure on their contents ; not, 
as has been commonly supposed, an alternate con- 
traction and relaxation, but a continued contractile 
effort, both longitudinally and transversely, which 
is overcome by the action of the heart : when there 
is much blood sent into them, they are distended ; 
and if there be little blood sent into them, as after 
haemorrhage, their tendency to contract causes them 
to close, so as to keep always full, and to preserve a 
continual stream of the blood, even during the tem- 
porary relaxation of the heart ; and the arteries 
yielding, and adapting themselves to the pressure 
of the heart, and recontracting on their contents, 
whilst the heart is relaxed and filling, is the cause 
of the equability of the stream in the veins ; nay, 
the stream even in the arteries is much less in jets 
than is supposed by those who judge from the 
mode of its flowing from a wounded artery : for 
though, when there is a free escape from the 


wound, the impulse of the heart causes an unequal 
stream, it must be remembered that in the tube 
unwounded that force would have been partly ex- 
pended in stretching the artery, whereas the artery 
when wounded ceases to be other than as a simple 
tube, the elasticity not being called into operation, 
on account of the escape of the blood from the 

The most simple mechanical illustration, per- 
haps, is the double bellows of a smith's forge, 
which keeps up a constant current of air, though 
the handle works with intermissions ; so that the 
blast into the fire would be in puffs, if it were not 
for the weight on the upper half of the bellows, 
which keeps forcing out the air in a continued 
current, whilst the hand is drawing back to make 
another impulse. 

It has been supposed that the circular fibres 
of the arteries were muscular ; that they con- 
tracted and relaxed at each pulse ; and that the 
throb felt was caused by a dilatation of the artery. 
Those fibres are not muscular, but more approach- 
ing to a ligamentous tissue,* firm, and, though elas- 
tic, not yielding to the force of the heart at each 

* This has been confirmed by the microscopical investigations 
of Schwann and Eulenberg (De Tela Elastica, Berolini, 1836) ; 
whereby the long- continued controversy concerning the muscu- 
larity of the arteries is completely set at rest. They have un- 
equivocally demonstrated that the middle coat of the arteries is 
composed of that peculiar elastic tissue {tela elastica) which con- 
stitutes the ligamentum nucha? of vertebrated animals, the liga- 
mentum flavum of the vertebral column of man, &c. No muscular 
fibres whatever can be detected intermixed with the elastic tissues 
of arteries, as cellular tissue alone connects the various tunics. 


beat, but, on the contrary, preserving the calibre of 
the artery uniform, as may be seen by laying bare 
an artery in a living animal, or when the artery 
is exposed in an operation : it is longitudinally 
that the arteries are stretched at each injection 
from the heart, by which their capacity is increased ; 
the consequence of which, from their being bound 
down in various places, is, that there is a serpen- 
tine motion in the artery where it is at all loose. 

The fibres of the middle coat of the artery, 
being arranged circularly, allow of the separation 
laterally, and thus accommodate themselves to the 
elongation of the tube, whilst they resist its dilata- 
tion. Now, it may be thought that the motion of 
the arteries seen at the wrist and in the temples is 
their dilatation ; but it is the serpentine movement 
caused by the alteration of the curve, the artery 
being elongated at each injection from the heart. 

Where the artery is perfectly straight, you 
may lay it bare and scarcely see it move ; but the 
moment you compress it with the finger, or tie a 
ligature round it, you perceive it pushed at every 
pulse. To illustrate the deception of the sensation 
which the pulse gives, as if the artery were dilated 
at each beat ; if a long vein, removed from the 
body, have a syringe adapted to one end, the other 
being raised, or arranged with a spring-valve, which 
yields to the jets so as to keep it full, and fluid be 
sent through in jets, it will, upon pressure by the 
finger, give the sensation of dilatation, but the eye 
perceives none. Again, if any one grasp the leather 
tube of a fire or garden-engine, the sensation given 
will be that of its expanding in the hand at each 


stroke of the pump ; but the eye contradicts the 
sensation : it is merely the tendency to resume the 
cylindrical form from the outward pressure of the 
fluid, but not expansion. 

Some writers have attempted to prove that the 
heart has an active power of dilatation,* by which 
it helps to refill itself by sucking in the blood, as it 
were ; and one proof is brought forward from the 
heart of any of the large mammalia, as the horse, 
ox, or whale, which affords the phenomenon of con- 
tracting and expanding after removal from the body : 
but the expansion is simple relaxation ; and when 

* The impulse of the heart against the side (which takes place 
just as the auricles have filled the ventricles, and the latter become 
rigid, commencing their contraction) is in proportion to its mus- 
cular action, and is produced by the heart assuming a form more 
approaching to the globular, and becoming firm at the same time, 
giving the hand a sensation similar to what is felt when it is applied 
to the calf of the leg or to the jaw, and their muscles put in action ; 
the heart being in an angle between the diaphragm and parietes 
of the chest, the increase of its transverse dimensions has the effect 
of the driving of a wedge, thus forcing itself against the ribs. 
Now, these actions may be very strong, but if they be too rapid, 
there is not time for the heart to receive the usual quantity ; so 
that, only a little being sent into the arteries at each contraction, 
the pulse may be small when the heart is acting strongly, as in 
palpitations : and an ignorance of this fact might lead to the 
administration of stimulants when not required, to say the least, 
if the pulse alone were consulted : ceteris paribus, " impulsion " 
is increased by hypertrophy, diminished by dilatation. The ven- 
tricles contracting on a small quantity produces the phenomenon 
of " impulsion ;" the ratio of thickness of parietes to cavity being 
altered gives a deceptive sensation, as if there were hypertrophy, 
which has misled many to predicate hypertrophy where it did 
not exist, in hysteric and other nervous states. The sounds of 
the heart are produced by the sudden tension of its valves. (See 


a large heart is relaxing, if the hands be pressed 
on opposite sides of it, they will be sensible of an 
apparently active expansion from the mere gravi- 
tating recovery of position of such a mass of mat- 
ter ; the heart, in fact, not opening actively, but 
falling open after each contraction. 

It will be shewn now by what means the blood 
fills the right auricle, which, being flaccid, is easily 
distended ; but it requires the muscular action of 
the auricle in addition to fill out the more dense 
ventricle, — this is the use of the auricle : it would 
be unnecessary if the ventricle had an active 
power of dilatation, natura (Deus) nihil agit frustra. 
It is the constant pressure and equable stream 
which refills and distends the right auricle of 
the heart after each contraction ; not any suc- 
tion, to use a vulgar expression, of the heart, or 
suction of the chest, as has been attempted to be 
proved ; no effect of vacuum and atmospheric pres- 
sure. There is no suction,* no atmospheric pres- 
sure, during natural respiration ; for the glottis is 
sufficient to admit a free current of air : it is only 
in croup, or laboured respiration of some kind, as 
of an animal under experiment, that there can be 
any effect of atmospheric pressure. 

A reference to the hydrostatic principle, of fluid 

* Sir David Barry endeavoured to demonstrate that a suction, 
or atmospheric pressure, was produced by the expansion of the 
chest, exerting an influence in promoting the circulation ; and the 
Committee appointed by the British Association to investigate 
the causes of the sounds of the heart have revived (1840) this 
opinion, which appears to me to be inconsistent with the laws of 


in bent tubes finding its level, will be sufficient to 
account for the capability of the heart to send the 
blood, with little effort, all over the frame, and for 
the refilling of the heart after each contraction. 
The heart sends the blood against the force of gra- 
vitation through but a small portion of the system ; 
for in all the natural positions, upright or horizon- 
tal, by far the greatest portion of it is below the 
level of the heart. Now the blood, being confined 
in the arterial and venous tubes, will, of course, on 
hydrostatic principles, return to the same level 
from which it flows : and as to the capability of 
the muscular power of the heart to inject the parts 
that are above its level, when any person compares 
the force necessary to be used in doing so, with the 
force which an equal quantity of muscle in the arm 
is capable of exerting, it appears trifling ; besides, 
whoever applies the hand to an aneurysmal tumour 
may judge of the power of the heart. The blood, 
then, returning from the parts above the level of 
the heart, tends to refill it by gravitation, even if not 
aided by the contractile pressure of the arteries ; 
the blood below the level of the heart, or rather 
arch of the aorta, returns by the tendency to find 
its own level ; so that the blood is pressed into the 
right auricle by the weight of the returning blood 
from all the parts above the level of the heart, 
added to the pressure caused by the difference of 
the height of the arch of the aorta above the right 
auricle of the heart, and, in addition, by whatever 
remains of the contractile pressure of the arteries. 
Another consideration has generally been omitted 
in calculating the power and facility with which 


the influence of the heart is communicated through- 
out the arterial system, which is, that any retar- 
dation which might take place from the friction 
through the tubes, is more than compensated by 
the sum of the branches being greater than each 
trunk from which they arise, so that the flow is 
facilitated ; whilst, on the hydrostatic principle of 
Bramah's press, though the injecting force of the 
heart is spread over a greater space, it is not 
weakened, being multiplied, not divided ; and in 
injecting the capillaries, hydraulic friction is com- 
pensated by capillary attraction. 

We must not consider the elastic contractile 
effort of the arteries as one of the moving powers 
of the blood, any more than the fly-wheel of a 
machine, or the weight on a double bellows, which 
only regulate motion, and are, in fact, a burden 
on the moving power, though they continue the 
motion for some time after the moving power had 
ceased to act. The moving powers are, the con- 
tractile force of the heart,* gravitation, and the 
hydrostatic principle above stated, of the tendency 
in fluids to return to the same level. 

By anatomical investigation, then, we ascertain 
that tubes of various dimensions, called vessels, and 
which are named arteries, veins, and absorbents, 
are apparatus of every process in the growth or 

* Let it not be objected, that some lower animals, which have 
no heart, have still a circulation : the alimentary canal performs 
the double function of stomach in making the blood, and heart in 
sending it on when made ; as, in my opinion, the contraction of 
the alimentary canal of the higher animals sends forward the 
chyle in the lacteals. 


removal of all parts in health, and in the swelling 
or wasting of parts in disease. Moreover, we must 
not forget, — and it is a circumstance to be recurred 
to perpetually, both in theory and practice, — that 
nerves, accompanying the arteries throughout, com- 
plete the apparatus. 

The nerves are whitish threads, which are 
distributed to every part of the frame, however 
minute ; communicating with the brain, for the pur- 
pose of informing it of what is going forward in 
different parts, as when any thing touches the hand, 
tongue, &c. ; and for the purpose of conveying the 
mandates of the will from the head to the muscles 
of voluntary motion ; and again, supplying to all 
parts nervous influence, which excites action. 

The nerves communicating with the brain do 
not blend as they unite into larger and larger 
trunks, but preserve their individuality, however 
aggregated, like threads in a skein, or strands in 
a rope. 

When we speak of the nerves supplying to all 
parts nervous influence, which excites action, refer- 
ence must be had to the spinal cord and sympa- 
thetic or ganglionic system, as well as to the brain. 

We have reason to believe that the nervous in- 
fluence is generated, or secreted, in the more vas- 
cular cineritious (grey) part of the nervous system, 
and conducted by the medullary (white) part ; the 
medullary part in the spinal cord and brain being 
an aggregation of nerves from the frame. 

It is necessary here to state distinctly my opi- 
nion respecting action, as depending upon the 


nerves. I consider that the muscles and capillary 
arteries, though differing in tissue, have each inhe- 
rent in their structures a faculty of contracting, 
organic contractility : this contractility being acted 
upon by the nervous influence, the result is contrac- 
tion, the nervous influence being discharged into 
them from the nerves ; and this discharge may be 
produced in a variety of ways, as by the blood in 
the heart or capillaries, the presence of food in 
the intestines, the electricity from a charged jar, or 
in muscle by the will, whether the operation be 
direct or by • ■ reflexion" — these being known agents 
of contraction in the animal. 

All organic action is contraction, produced by 
nervous influence. This is termed by Bichat, con- 
traction from " organic contractility," resulting from 
" organic sensibility," which he distinguishes again 
from animal sensib'lity ; thereby making it appear 
that the nerves act upon an ideal inferior sensitive- 
ness in the structures, not confining sensitiveness 
to the nerves, Now, by his " organic sensibility " 
must not be understood sensitiveness, but that lia- 
bility, or capability, of. structures to answer to ner- 
vous influence, in the same manner that steam or 
any other agent produces action in a mechanic 
structure ; this is, in fact, organic contractility : so 
that he divided one property into two. 

What Bichat calls animal sensibility, is that func- 
tion of the nervous system alone by which commu- 
nication is kept up with the sensorium, and by which 
pleasurable and painful impressions are perceived : 
his animal contractility is merely organic contracti- 
lity of voluntary muscles called into action by the 



will ; but I would not give organic contractility a 
new name,, merely on account of the different 
orders of muscles receiving their influence in one 
instance from voluntary nerves, and in the other 
from involuntary nerves. Pain is the result of in- 
jury done to the nerves, and nerves alone, the 
union of nerve with other tissues being only to 
convey sensation, or to effect action : sensibility, 
therefore, is in the nerve. When pain takes place 
from injury, in parts which, though not under the 
control of the will, are still abundantly supplied 
with (organic) nerves to produce action, as in 
the heart or intestines, Bichat says this pain is 
" organic sensibility (action*) augmented " until it 
" becomes f animal sensibility," (Systeme CapilL 
§ vi.) ; but, on the contrary, it may be seen that 
" organic sensibility" (action) is diminished in parts 
where there is pain (in the sensitive nerves) from 

In fine, I prefer the term organic action to 
organic sensibility, and do not make use of the 
term " animal" sensibility at all. I use only the 
terms, organic action, and organic contractility, of 
the contractile tissues ; and sensibility, of the 

Bichat, I repeat, makes an ideal inferior sensi- 
tiveness in the structures, not confining sensibility 
to the nerves, as he says, " the nerves are strangers 

* It is impossible to separate them. We know nothing of 
organic sensibility or organic contractility, except so far as evinced 
by action taking place. 

f As they depend on different sets of nerves, one cannot 
" become" the other. 


to organic sensibility:" this leads him to become 
visionary, when he speaks of the lacteals exerting 
a choice as to what particles they will take up ; 
which is mere chemical or nervous effect on their 
tissues, making them cease to absorb what is un- 
fit for them, whether that be by the unfit matter 
causing them to contract and shut against it, or to 
relax so as to lose power ; still no election in them, 
any more than elective affinity of chemistry. From 
thus refining too much upon the functions as con- 
nected with vitality, he overlooked the more simple 
explanations which physics afford, and says that " it 
is ridiculous to attempt the explanation of the phe- 
nomena of changes in animal functions by mechani- 
cal laws and the variations in dimensions of vessels, 
&c. ;" but I think I have shewn, that what he calls 
vital laws, are but these mechanical laws modified 
by the Deity : we do not know the intimate struc- 
ture or mechanism by which a muscle or capillary 
contracts ; but doubtless it is as simple as a pair of 
lazy tongs, and as easily excited to action as they 
are by the hand, or the piston of a high-pressure 
engine is by the steam. There is no subject more 
interesting, no pursuit more gratifying, than this 
investigation of the properties and processes of our 
animal frame : there is no subject of contemplation 
which gives us so exalted an idea of the omniscience 
of the Deity, and so humble an opinion of all human 
inventions, as the excelling utility and efficiency of 
all its parts. How beautiful, how wonderful, then, 
must be the Soul, when such infinite wisdom, such 
exquisite arrangements, are lavished on the struc- 


ture which it is destined to inhabit for but a short 
space of time ! Such perfection in our organisa- 
tion leads us to believe with Job, that, however 
disarranged by death and decomposition, it may 
again be called into re-union, and that " in our 
flesh we shall see God." 

The animal heat has been accounted for in 
different ways by several ingenious physiologists: 
from the aggregate of their opinions and experi- 
ments I deduce, that heat is extricated all over the 
frame ; in the capillaries, by the action of the nerves 
during the change of the blood from scarlet arterial 
to purple venous ; and also whilst it is changing in 
the lungs from purple to scarlet. 

There is a perpetual deposition, by the capillary 
system, of new matter, and decomposition of the old, 
all over the frame, influenced by the nerves : in 
other words, the galvanoid or electroid influence 
of the nerves, which occasions these depositions 
and decompositions, keeps up a slow combustion. 
In this decomposition there is a continual dis- 
engagement of carbon, which mixes with the blood 
returning to the heart at the time it changes 
from scarlet to purple ; this decomposition being 
effected by the agency of the nerves, produces con- 
stant extrication of caloric : again, in the lungs that 
carbon is thrown off and united with oxygen, during 
which caloric is again set free ; so that we have in 
the lungs a charcoal fire constantly burning, and 
in the other parts a wood fire, the one producing 
carbonic acid gas, the other carbon; the food sup- 


plying, through the circulation, the vegetahle or 
animal fuel from which the charcoal is prepared 
that is burned in the lungs. 

It is thus that the animal heat is kept up : on the 
other hand, the evaporation of perspiration keeps 
the surface cool ; but in inflammatory fevers, where 
this is deficient, the body gets too hot ; and in low 
fevers, when the nervous influence is not sufficient to 
keep up the full fire, the surface gets cooler than the 
natural standard. This is peculiarly evident in the 
beginning of eruptive fevers, as scarlatina, where 
there is strong heat, with the arterial colour of the 
skin ; but if the same becomes malignant and low, 
with deficient arterialization, the temperature sinks, 
and the diminution of the charcoal combustion in 
the lungs is evinced by the dusky colour of the 
skin, shewing that the carbon is not thrown off as 
it ought to be : and the same phenomenon takes 
place in typhoid cases. 

Whatever nervous influence may be, or how- 
ever generated, we know that the energy of parts 
depends upon a something that is communicated 
to them by the nerves in conjunction with the gan- 
glia, brain, and spinal cord ; that while parts are 
supplied with this nervous influence, they retain 
their power of action, and not longer ; that arteries 
become less susceptible of impression from external 
agents when the nervous energy is low ; that when 
the vital powers are sunk, the capillary arteries 
cease to secrete ; that various phenomena in the 
healing of inflammation are the effects of healthy 
action of the heart and arteries. We find likewise 
when nervous energy is deficient, that parts which had 



advanced to a certain stage of healing become flabby, 
as in stumps after operation when the patient sinks ; 
and that when the power of the constitution, the 
nervous energy, fails, nitrate of silver will have no 
effect upon ulcers, except chemical decomposition 
— not that astringent effect which is the result 
of contractility depending on vitality. It is well 
known, likewise, that a blister not rising from a 
cantharides plaster is a bad sign, as being an evi- 
dence of approaching, or rather commencing, 
death ; this must not be confounded with a want 
of action in the arterial capillaries — the cause 
here is a want of injecting force in the heart ; but 
no vesication will take place even from boiling 
water, when the vital powers are sunk, as the heart 
has not power to effuse serum. This is a more 
satisfactory example than cantharides, because the 
effect of the hot water goes so far as to produce 
the local injury, for the cuticle may be sepa- 
rated or loosened by the mere chemical effect of 
the heat; but this takes place equally in a dead 

With respect to the action of the heart, all are 
agreed that its action is contraction, by which the 
blood is sent forward in the arteries, and that the 
power of the heart's action is measured by the 
pulse when there is no organic alteration, such as 
ossification of the valves at the beginning of the 
aorta, aneurysm, &c. 

The action of the arteries also is acknowledged 
to be contraction, whether considered muscular or 
not ; but there is some difference of opinion as to 


the degree of action of the arteries in inflamed parts. 
It is very common to say, that in inflammation 
there is an increase of arterial action ; but a consi- 
deration of the phenomena, and of the nature of 
arterial action, will shew that in inflamed parts 
the capillary arteries are weaker in their action ; 
that there is diminished arterial action, for the 
action of arteries is contraction : now the arteries 
in inflamed parts are evidently larger than before 
— less contracted, that is, acting less. 

An inflamed part is redder and swelled ; where 
the vessels are visible, as in the eye, we can 
see that the redness is caused by the minute ves- 
sels becoming larger, so as to admit more blood. 
This enlargement of vessels is not from increased 
action, but, on the contrary, from their action 
being diminished, their giving way and being di- 
lated by the injecting force of the heart. The 
way to diminish the inflammation is by increas- 
ing the action of the arteries, as by cold or astrin- 
gents, which make the arteries contract, that is, 
increase their action ; so that, so far from the 
arteries in an inflamed part being in a state of 
increased action, one of the means of diminishing 
inflammation is by increasing arterial action in the 
part inflamed. It is common to remark the throb- 
bing of the carotid arteries as increased action ; but 
the more they throb, it shews that they the more 
yield to the injecting force of the heart. When 
the eye, or any other part, is injured by heat, or a 
stream of cold air, a blow, or cantharides plaster 
applied to the skin, &c, the part becomes redder 
from the vessels enlarging and admitting a greater 


proportion of blood than there was before. Now 
in this first and simplest instance of inflammation 
the heart does not act more strongly than ordinary, 
not affecting the pulse ; so that the capillary arte- 
ries evince debility, having given way when there 
is no more force than they bore before without dis- 
tension : from this they sometimes recover of them- 
selves, gradually contracting to their natural size ; 
or if not, the simple application of cold, or an astrin- 
gent lotion, makes them contract, and the redness 

It is the opinion of some persons, even at the 
present day, that the motion of the blood is acce- 
lerated in inflamed parts ; though the experiments 
of Parry and others proved the contrary to be the 
case, as follows from the capillary arteries being 
enlarged ; inasmuch as when fluid passes through a 
given space, the current beyond that will be slower 
in proportion to the wideness of the channel; as in 
a wide part of a river, where the current becomes 
slower : and the same may be observed by passing 
water, mixed with grains of amber, through a glass 
tube with a bulbous enlargement in the middle ; 
the current will slacken in the bulb, and resume its 
velocity beyond it. 

Some will allow that the capillary arteries, where 
the blush of inflammation is, are weak, as they visibly 
have given way ; but they still speak of increased 
arterial action, and say that the arteries around 
or leading to the inflamed part are in increased 
activity, as a part of the condition, or of what 
keeps up the inflammation ; not considering that an 
increase in their action would be contraction, and 


consequently a diminution of the flow of blood to 
the inflamed part : in fine, an increased action in 
the arteries both in and leading to the inflamed 
part, is just what is required to diminish the in- 

But so far from" the arteries leading to the in- 
flamed part being in a state of increased activity, 
we have obtained evidence that they also become 
weak when the inflammation continues for some 
time. Hausmann, to whom we are indebted for 
many valuable experiments on inflammation, has 
made a series of preparations of the leg of the 
horse, in which inflammation had existed, shewing 
the participation of the larger arterial trunks in the 
inflammatory condition of the capillaries, dilatation 
having spread from the minute vessels of the part 
inflamed to the main arteries of the limb. The in- 
creased throb which is apparent in these during life 
confirms my remarks on the subject, that the throb 
and full feel of the pulsation is an indication of the 
artery having given way to the injecting force of 
the heart. Another argument brought forward by 
the advocates of increased arterial action in inflam- 
mation is, that an incision in an inflamed limb, as in 
phlebotomy or arteriotomy, will bleed much more 
freely than the corresponding sound one, — to which 
I would answer, that it simply demonstrates that the 
arteries contain more blood, in consequence of hav- 
ing become enlarged from diminished action. 

The more the heart acts, the more of course it 
forces the arteries of the inflamed part ; and the 
pulse, shewing the power of action of the heart, is 
erroneously by some considered as an evidence 


of arterial action ; the throbbing of the carotid 
arteries, for instance. As the heart, therefore, acts 
against the capillaries, if we cannot cause them to 
contract strongly enough to resist its force, we are 
obliged to diminish the force of the circulation, 
either by taking away blood, which decreases both 
the quantity of blood sent to the arteries and the 
action of the heart itself, and in this way we leave 
less for the arteries of the inflamed part to do ; 
or, we can lower the force of the heart by medi- 
cines, such as digitalis, &c. Here, for illustration, 
the simplest cases of inflammation have been 
taken, in which the heart is acting naturally, the 
inflammation being from injury. 

Sometimes parts are loaded with blood when 
we cannot find evidence of inflammation, and which 
state is called congestion. Inflammation or conges- 
tion are but varieties of distended vessels, which, if 
they cannot unload themselves, we assist by appli- 
cations or medicines which make them increase 
their contractile action ; or if that alone is not 
sufficient, by taking off some of the force which 
injects them, or, as it is called, the vis a tergo. 

The difference between congestion and in- 
flammation is, that in congestion there is merely 
distension of the vessels ; in inflammation there is, 
in addition, alteration of tissue — actual deteriora- 
tion, more or less, of the structure of the capil- 
laries. Thus congestion may be produced in a 
part by a ligature ; by the pressure of a tumor ; 
by obstruction to the course of the blood, as by 
diseased valves of the heart : and vessels thus con- 
gested may remain so for a great length of time, 


and quickly resume their natural state, when re- 
lieved from the pressure of obstruction ; in fact, 
the vessels cannot be said to be diseased. But the 
case is different with inflammation ; the fault com- 
mences in the tissue. As soon as a want of that 
harmony between the nerves and capillaries, which 
is necessary to organisation, takes place, their fine 
tissue begins to decompose, the particles which 
were held together by this inscrutable agency be- 
gin to be precipitated from one another ; and this 
takes place in every shade and degree, from the 
slightest scorch of the fire, or blush from the 
wound of an insect, to mortification and putrefac- 

When the valves of the heart are diseased, the 
obstruction thereby caused to the circulation pro- 
duces congestion in the lungs, which is very dif- 
ferent from the state of inflammation or peri- 

Let us see how far we can go in proving that 
the capillaries depend upon nervous influence for 
their contractile action. Blushing is, perhaps, the 
most unequivocal proof that an alteration in the 
nerves is the cause of sudden dilatation of the 
capillaries. It is not the action of the heart alone 
which causes the partial flush ; for, first, the heart 
often acts stronger without causing blushing, and, 
next, the blush is partial ; whereas, when the mere 
action of the heart causes increased redness of 
the skin, as from exercise, it is not partial, as it is 
in blushing from mental emotion. And this, which 
is sudden weakness of the capillaries, has been 
commonlv attributed to the " increased arterial 


action/' and " determination to the face." I attri- 
bute this giving way of the capillaries to derivation 
of the nervous influence, which, being directed to 
or expended in the brain more freely by mental 
emotion, robs, for the moment, the capillaries of 
the face of their energy. 

What is called the blush of inflammation may 
be brought on in a part by reiterated strong elec- 
tric sparks. It may be said that the effect of the 
electricity is on the tissue of the capillaries; but 
the first effect produced is pain, shewing that the 
operation of the electricity commences on the 
nerves, sensitive as well as organic* The same 
observations are applicable to the blush produced 
by heat from a fire ; and we have a proof that 
this is the effect of nervous influence before in- 
jury or alteration of the structure of the ves- 
sels, by the common experiment of those who 
have resolution to hold the burned or scalded 
part to the fire, and remove it gradually, which 
will prevent the disorganisation that would other- 
wise take place — in common language, prevents 
blistering. The mischief is caused by exhaustion 
of the nervous influence ; the sudden removal of 
the excitant leaves the capillaries destitute, and 
they yield immediately to the ordinary injecting 
force : but if the excitation be renewed, by holding 
the part to the fire, nervous influence is supplied 

* An animal may be killed by a strong electric shock, or by 
lightning, and not the slightest injury of the vascular tissues be 
discoverable by dissection ; and as we know that the nervous 
tissue is the part affected by electricity, its lesion must be in- 
ferred to be the cause of death. 


from the neighbouring parts to the capillaries, with 
pain certainly, but, by slowly removing from the 
heat, the nervous influence will be gradually sup- 
plied, till the excitant be reduced to a natural 
standard, relieving the pain and incipient inflam- 
mation. On the same principle may be explained 
a fact pretty generally known, that if melted seal- 
ing-wax be dropped on the skin, and be immedi- 
ately removed, the skin will blister, or at least feel 
scorched, and remain painful for some hours ; but 
if the wax be allowed to cool gradually before re- 
moval from the skin, the pain, though severe dur- 
ing the cooling, ceases immediately, and no blister 
arises. These I consider to be proofs that the 
diminution of nervous influence, rather than altera- 
tion of tissue, is the proximate cause of the relaxa- 
tion of the capillaries ; for if it were alteration of 
the tissue, not diminution of tone, the renewal of 
the heat would add to the previous mischief, in- 
stead of affording relief. 

The progress of inflammation shews the de- 
pendence of the capillaries on the nerves. A part 
may, in certain cases, be observed to become tender 
before it is red ; for it may be observed by experi- 
ment that the pleura or peritoneum of an animal 
is not extra-sensitive immediately on exposure ; it 
first becomes tender, and then red. In inflamma- 
tion of the conjunctiva of the eye, it is painful, 
feeling as if there were sand under the lid, some 
time before its vessels are enlarged. The pain of 
Erysipelas precedes the redness. The action of 
cantharides in producing inflammation, is another 


proof that inflammation begins in the nerve ; for 
cantharides have no effect on the tissue of the 
capillaries, do not corrode or act in any way on 
their substance after death, when the nerves have 
no influence ; whereas any really corrosive agent 
would act even more on the dead than on the 
living capillaries. Without, therefore, at present I 
seeking for further proofs, I deduce from blushing, 
and from the effects of electricity, fire, and cantha- 
rides, that the capillaries are dependent upon the 
nervous system for that tone or energy which pre- 
serves them from over-distension. The brain, spi- 
nal cord, and nerves, again, depend upon the due 
nutrition afforded by the arteries, which supply 
them with scarlet blood. 

Though Bichat denies the influence of the 
nerves, or says that it is almost nothing, in secre- 
tion, exhalation, &c, I consider that the sudden 
alterations of these from mental emotion prove the 
contrary ; besides the proofs already advanced, 
that capillaries, which are the agents of these 
functions, derive energy from the nerves. 

A cautious application of electricity to an eye red 
from chronic inflammation will cure it. Spirits, oil 
of turpentine, squills, even solution of cantharides, 
&c, applied to a wound, or, through the circulation 
to a secreting organ, will cause the capillaries to 
contract ; in reality, stimulate them to action (con- 
traction). But the same agents, applied too strong, 
exhaust the nervous influence, and relaxation (which 
has been erroneously called arterial action) takes 
place. This will account for the use of certain 


remedial agents to diminish inflammation, which, 
when pushed a little farther, irritate, and subse- 
quently produce inflammation. 

It is sometimes remarked, that " local irritation 
detains the blood " in a part, as if by some obstruc- 
tion or attraction ; whereas this phenomenon may 
be explained by the increased capacity of the ves- 
sels causing a slower current, as before stated, 
thereby allowing the blood to be delayed. Besides 
the expression detention, and the terms congestion 
and inflammation, there is another word, determi- 
nation, used to express an habitual reception of 
more blood than natural in a part ; as, " determi- 
nation of blood to the head, with throbbing of the 
carotids." The throbbing of the carotids has been 
already explained not to be active, but passive. 
Now, the word determination, in ordinary lan- 
guage, implies that blood is sent somewhere in 
particular ; but the heart has no power to direct 
any blood to one part more than another, although, 
if in any part there be an unusual relaxation of the 
vessels, they will receive more than ordinary ; as, 
when the water is sent through the main pipe of 
one of the water-works, it cannot be determined to 
any house in particular, but whichever house has 
the largest cistern will receive most water.* By 

* We have an interesting physiological illustration of this 
principle in the " determination " of blood alternately to the 
stomach and spleen. A given quantity of blood is constantly 
sent through one arterial channel, which branches off to the sto- 
mach and spleen : when the stomach is empty and collapsed, its 
arteries being likewise collapsed, the blood passes into the spongy 
texture of the spleen, so constituted and situated as to be ready 
to receive it ; on the contrary, when the stomach is distended 



this I wish merely to illustrate, that what is called 
determination is not active, but passive. The term 
also used by Bichat, of the blood being drawn or 
invited into an inflamed part, may be explained on 
the same principles. 

Irritation, continued excitation of the nerves of 
a healthy part, as just shewn, at last produces in- 
flammation, by exhausting that nervous influence 
which gives the capillaries power; they thus be- 
come weakened, allow of over-distension, and the 
part is in the state of inflammation or congestion. 
This effect may be produced by electricity, which 
acts palpably through the medium of the nerves ; 
so that redness produced in this way is as evi- 
dently through the abstraction of nervous influence 
as blushing. 

Thus, in a part inflamed there is a diminution 
of organic action, in consequence of which the 
blood is admitted in excess. As long as the capil- 
laries are supplied with nervous influence, as long 
as they possess perfect organic action, they preserve 

with food, its elongated arteries admit the blood freely, and con- 
sequently the spleen, being then less forcibly injected, collapses 
and contains less blood. The spleen thus performs the office of 
a mill-pond, by receiving the surplus of the stream when not 
required for the mill, the stomach ; and, by this contrivance, the 
quantity of venous blood sent to the liver from the two organs 
does not fluctuate. I have never found reason to alter this 
opinion respecting the use of the spleen, which I advanced in my 
Thesis. Again, we have an illustration from comparative physio- 
logy : according as the lungs and thorax become developed in 
the tadpole, there is an increased development of arteries and 
capillaries, exactly equivalent to what is called determination; 
but the increased influx of blood is merely the result of increased 
vascular capacity. 


a due size ; when they lose it, either from the in- 
fluence not being supplied from the nervous system, 
or are robbed of it by heat, electricity, cantharides, 
or other cause, they give way, and admit more 
blood than before. Taking this view of the proxi- 
mate cause of the enlargement of capillaries, we 
can account for all varieties of congestion, from a 
simple transient blush to the stage with which in- 
flammation commences ; and it must be impossible 
to draw a line between congestion and inflam- 
mation, one passing into the other by insensible 
shades. Hence the numerous terms used by au- 
thors to express the gradations of distended capil- 
laries : congestion active and passive, engorgement, 
hyperemia, erythema passing to erysipelas, &c. 
When the congestion or inflammation subsides 
without solution of continuity, or leaving any trace 
behind, it is called resolution ; and it is very in- 
telligible how cold and astringents promote this 
desirable termination ; as does also a means not so 
commonly applied, an even bandage with gentle 
general pressure over an inflamed limb. 

This leads to an explanation of the diminution 
of secretion in an organ, at a time when it is, in 
fact, fuller of that material (the blood) from which 
it secretes, than ordinary, as the kidneys, the skin, 
&c. ; and enables us to account for the dryness of 
skin and scanty secretion of the kidneys in fever, 
&c, without reference to Cullen's doctrine of spasm, 
by an increase in diameter of the capillaries ; not 
from obstruction, but, on the contrary, from too 
much room. 

Secretions are carried on by fine capillaries, 



which, by their great number and extreme minute- 
ness, envelop, in the form of a vascular membrane, 
the ultimate or terminal ramifications of the excre- 
tory ducts of all glandular organs : for by the re- 
searches of Muller, Weber, Rathke, Kiernan, &c, 
into the intimate structure of the glands of adult 
animals, and those of Muller, Von Bar, and others, 
into the mode of embryonic development and 
growth of glands, the correctness of the opinion 
of Malpighi, Cruikshank, &c, is demonstrated, viz. 
that the greatest analogy exists between them and 
the most simple mucous crypt of the intestinal 
mucous membrane, or cuticular sebaceous follicle ; 
that, in short, a gland is made up of innumerable 
cryptae, which are ramifications of the excretory 
duct, each ultimate (and in most organs by aid of 
the microscope alone visible) branch of the excre- 
tory duct terminating by a blind extremity, in the 
parietes of which are distributed the finest capil- 
laries. These capillaries are many times smaller 
than the cryptae, follicles, tubuli seminiferi, tubuli 
uriniferi, &c, as they are called, in different organs, 
and do not communicate with them by open or 
terminal extremities, as Ruysch and later anato- 
mists have supposed ; on the contrary, the finest 
capillaries are seen to join with one another, so as 
to form again larger and larger trunks, then called 
veins. Secretions, therefore, are vital transudations 
from the capillaries into the excretory tubes of the 
glands, by pores invisible to our senses, even when 
aided by the most perfect optical instruments. We 
see here the wonderful contrivance by which an 
enormously large surface is obtained for the pur- 


poses of secretion : a gland being strictly compara- 
ble to a mucous or serous membrane so convoluted 
upon itself as to occupy as little space as possible 
in the economy of animal bodies, having one or more 
outlets left (the excretory duct or ducts, or sum 
total of all the excretory tubes), by which the 
secretion is emptied into its proper receptacle. 
Not the least interesting point in our present 
knowledge of the structure of the glands, is the 
strict analogy shewn to exist between all glands 
and the lungs. Indeed, owing to the compara- 
tively large size of the individual parts constituting 
the lungs, and, consequently, the facility with 
which their minute anatomy may be investigated, 
they may serve to illustrate, by analogy, the struc- 
ture of the apparently more complicated, because 
with greater difficulty investigated, glands. The 
latter, as just stated, consist of an excretory duct 
or ducts, which subdivide, as if ad infinitum, first 
into tubes and branches of first, second, third, and 
fourth orders ; and at last into (acini, consisting 
of) clusters of the finest pouches or follicles, the 
parietes of which are enveloped in a net-work of 
capillaries. It is precisely the same with the 
lungs : composed of an analogue called the tra- 
chea, the branches of first, second, third, and 
fourth orders are the bronchial tubes, which at 
their ultimate terminations, after the most elabo- 
rate branching out, present clusters of minute 
cells, which represent the acini or clusters of mi- 
nute cryptae or follicles. The air-cells of the lungs 
have, like the glandular cryptae, their beautiful net- 
work of capillaries, from which the hydrogen and 


carbon, or carbonic acid and water, are secreted, 
without there being any direct communication be- 
tween them and the capillaries themselves. The 
lungs, however, are adapted for something more 
than a glandular purpose : they convey to the 
blood the material for aiding its purification, its 
secretion of carbon, &c. ; for whether the atmo- 
spheric air carried into the lungs be merely a 
vehicle for carrying off, according to Lavoisier, La- 
place, and Prout, carbon and hydrogen secreted 
from the blood ; or in order to afford oxygen for 
absorption by the blood, to be subsequently se- 
creted in the form of carbonic acid and water, as 
Sir Humphrey Davy and the majority of chemists 
suppose, — the peculiarity of the lung, besides its 
analogy with the glands, remains.* From the free 
anastomosis between all the capillaries in a secret- 
ing organ, and their gradually forming larger and 
larger vessels constituting veins, without any di- 
rect communication with the tubes, cryptae, or fol- 
licles, into which the secretion takes place, (except 
by pores necessarily imagined to exist, although 
unseen,) being proved, so that whatever of the 

* As all secretions are effected by the (galvanoid) agency of 
the nerves on the blood in a series of capillary tubes, it becomes 
an interesting object of physiological inquiry, how far the mere 
change of form in each glandular organ — merely by alteration of 
number and series of capillaries and nerves, as modelled on the 
ramifications of the excretory duct, the true element of the gland 
— produces secretions apparently so different, but, after all, differ- 
ing only in the proportion of atoms of the four constituents, car- 
bon, hydrogen, nitrogen, and oxygen, which are found in all, 
with a different proportion of the saline constituents of the blood 
appropriated to each. 


blood is not secreted is returned, — it does not fol- 
low, that where there is diminished secretion, there 
is obstruction ; on the contrary, there may be more 
space for the flow, but then in a slower stream : 
for, as has been shewn, the consequence of enlarge- 
ment of the capillaries of a part is, that the flow of 
blood will be slower in them, the supplying arte- 
ries remaining the same ; the larger the capillaries 
supplied by these branches, the slower the current 
will be, as in the skin, kidneys, serous membrane, 
salivary glands, &c. Hence, to account for the 
diminished secretion, it is not necessary to sup- 
pose either any " spasm," or " error loci of the red 
particles, getting into the colourless capillaries :" 
it is enough to consider, that the fluid finds an 
easier way, by the enlarged capillaries onwards 
into the veins, than through the pores in the capil- 
laries into the ramifications or cceca of the excre 
tory tubes, unfitted as the capillaries are for secre- 
tion, owing to the morbid alteration of their physical 
condition ;* and besides, yet more particularly, 
through the alteration of their dynamic (galvanic 
or electrical) condition, consequent upon the alte- 

* The pores must become obstructed by the swelling (thicken- 
ing) of the parietes of the cceca ; as a dry cask or a wooden vessel 
perforated with small holes will allow fluid to pass through ; but 
if the wood be thickened by soaking in water, the pores become 
closed up. It is evident that the cceca themselves must be nar- 
rowed by that congestion or enlargement of the net- work of capil- 
laries surrounding them, which is produced by inflammatory re- 
laxation, as is well known to take place in hepatitis, nephritis, &c. 
We can understand, too, that the tubes themselves may be thick- 
ened, until their calibre is obliterated by the internal swelling of 
their substance, as takes place in inflammation of the liver, &c. 


ration of the supply of nervous energy to the part, 
the original cause of all the disturbance. Local 
enlargement of capillaries explains that kind of 
diminished secretion where the heart is not defi- 
cient in injecting power; the relaxation of the 
capillaries, from want of nervous energy, produc- 
ing a deficiency in the current of the blood ; as in 
a dry skin when inflamed or feverish, or kidneys 
inflamed, or their capillaries enlarged by cantha- 
rides, so as to diminish secretion, in the manner 
just explained. 

In some cases of disease, when the secretions of 
the skin and kidneys are deficient, we renew them 
by bleeding, digitalis, antimony, &c, which lower 
the force of the pulse, thereby diminishing the dis- 
tension of the capillaries, in conformity with the 
above statement. On the other hand, in health, 
stimulants, such as fermented liquors, by increas- 
ing the nervous energy in the kidneys, &c, and 
quickening the circulation at the same time, in- 
crease secretion ; and this takes place in a greater 
degree, if some astringent, such as lemon-juice, be 
combined, as in the form of punch. Or, medicines 
such as uva ursi, digitalis, antimony, neutral salts, 
&c, have also this local astringent effect when cir- 
culated, besides their influence on the pulse. Sti- 
mulants can not increase secretion by quickening 
the circulation, when the capillaries are in a state 
of debility and morbid congestion ; and a still far- 
ther proof that they are in a state of morbid con- 
gestion, is the effect of cold to the loins in such 
cases in renewing the secretion ; and the con- 
stringing effect of cold water, even cool air, in 


promoting the secretion of insensible perspiration, 
and thereby softening the congested skin, in scar- 
latina. Increased secretion takes place sometimes 
with a weak pulse. It will be found that this 
occurs in cases where, although the circulation is 
weak, the capillaries are not congested, as in hys- 
teria, in the sweating of hectic, and also in the 
sweating stage of ague, after the hot, dry, con- 
gested stage has passed off, analogous to what was 
stated above of the effect of cold in scarlatina. In 
these cases there is a deficiency of nervous influ- 
ence, which, if the heart were acting strongly, 
would cause parts to flush ; as we see, in fact, in 
the flushing alternations in hysteria, hectic, &c. 
But when the heart is not acting strongly, and 
there is a debilitated, ansemial, or flaccid state of 
an organ, the kidney for instance, which produces 
a limpid state of the secretion, this may be coun- 
teracted by giving either diffusible stimulus to in- 
crease the force of circulation, or local stimulus, such 
as turpentine, or a combination, as sp. junip. co. &c. 
which, when circulated to the kidney, by eliciting 
more nervous influence, will restore the organ to 
its natural dynamic state, and thus both diminish 
the morbid secretion and render it less limpid. As 
soon as the local stimulus of the turpentine be- 
comes excessive, it gives pain in the back, and 
diminishes the secretion too much ; affording an 
illustration of the circumstance that different doses 
of medicines produce most opposite effects. 

The healthy operations of the arteries have 
been mentioned, as far as their continued and 


gradual deposition of matter in its various modi- 
fications from solid bone to gaseous exhalation. 
Their depositions are very gradual, in proportion 
to the whole quantity of blood passing through 
them, a great portion of which returns by the 
veins unchanged, or at least unconsumed ; so that 
there is always an abundant overplus for the de- 
mands of the system, and this provides against 
accidental or artificial loss of blood. 

Whilst the processes described go on, the ani- 
mal suffers no inconvenience — is in health ; but 
when accidental mechanical injury, or other cause, 
changes the action of the capillaries, either by a 
direct impression on themselves, or by primarily 
injuring their nerves, the derangement of their 
action is the commencement of disease — secretions 
become altered, checked, or profuse — nutrition is 
either diminished, so as to produce emaciation, or 
there is an excessive deposition — vapoury exhala- 
tions are diminished to dryness or increased to 
fluid — bony matter is deposited in wrong places, 
or albuminous, fatty, and other particles, so as to 
constitute tumours — the nerves of parts become 
morbidly sensible, so as to derange the functions 
of those parts — portions, on losing their vitality, 
undergo spontaneous decomposition, and are re- 
moved by the absorbents. 

To explain this more in detail : every disease 
is some alteration of those actions which, when 
perfect, constitute the welfare of the animal ; and 
in some instances, by a provision of nature, the 
newly altered action, which is the consequence of 
the injury, leads to the reparation of the damage, 


without assistance from art. For instance, the 
tubes conducting the air through the lungs are, 
under ordinary circumstances, scarcely moist ; but 
if particles of dust, or insects, be inspired, the re- 
sulting irritation causes morbid sensibility, is fol- 
lowed by the extra-production of mucus, entangle- 
ment of the foreign substance, and its evacuation 
by cough. 

We also see that where a part is cut, the 
minute arteries conveying coagulable lymph allow 
the escape of a sufficiency of it to glue and unite 
the surfaces, if kept quietly in contact — called 
technically union by the first intention ; and we 
know that, not merely a part partially severed 
will reunite, but even a piece wholly cut off, if 
small, and not depending on vessels of any size, 
will reunite by the first intention ; as the top of 
a finger or a thumb, including even a bit of the 
bone, which had been cut off by an artisan with 
a sharp tool, has been replaced and has reunited. 
This is analogous to the Hudibrastic version of 
the Taliacotian operation ; but as opportunities 
of witnessing such circumstances are rare, some 
knowledge of physiology, and a reference to 
J. Hunter's experiments, are requisite to enable us 
to believe the fact. 

When blood is allowed to stand in a vessel, 
the upper part of the clot which settles down from 
the serum, of a yellowish-white colour, affords a 
specimen of coagulable lymph, carried in readiness 
to repair damages. 

Now, if the union by the first intention be pre- 
vented by disturbance, it becomes necessary that 


the surfaces should be reunited by the interposition 
of a new substance forming a connecting medium : 
for this purpose small drops of coagulable lymph 
are exuded, which concrete, remaining at the cut 
ends of the capillary arterial branches which have 
yielded them, and in communication with these 
open ends, so as to become organised and receive 
nourishment by the capillary growing longer, and 
continuing itself onwards into the lymph. These 
little portions of coagulable lymph are called gra- 
nulations ; and - if they are not much disturbed, 
they adhere to each other, and thus the cementing 
of the divided part is effected, and even a consi- 
derable gap is sometimes rilled up by granula- 
tions springing from granulations. This spongy 
mass gradually condenses, forming a firm bond of 
union, generally distinguishable, and is called cica- 
trix. Wherever solution of continuity of the skin 
is not healed by the first intention, a visible cica- 
trix remains, as the newly formed solid has not 
the same degree of vascularity as the surrounding 
tissues. In order to protect the new tender gra- 
nulations, they are covered with pus ; a creamy, 
thick fluid, which, when of a due consistency, is 
very properly called healthy pus, for it requires 
a healthy action of the capillaries to produce it in 
proper quantity and of due consistency* If pus 
did not defend the granulations from the air, they 
would dry and become scabs, instead of uniting 
and repairing the parts ; if the secretion be too 
thin, so as to become ichor instead of pus, shewing 
a debility in the capillaries, we have, from that 
same cause, weak, spongy granulations, or even 


none at all are formed. An ulcer which, whilst 
healing, appears a large ugly sore to the inexpe- 
rienced eye, is called by the surgeon a fine healthy 
granulating surface ; and often, to obtain this 
healthy process, the exercise of much skill, both in 
local and constitutional remedies, is required ; as, 
for instance, to heal an ulcer, a wound, a stump, 
or other part after operation. This is sufficient 
example of the necessity of a surgeon being well 
acquainted with the use of constitutional reme- 
dies ; and the most dexterous, after performing an 
operation, may be glad of a knowledge of medicine 
to relieve subsequent constitutional symptoms. 

Many persons of great experience practise well 
empirically without much brains or reasoning ; but 
he who begins upon principle, and then profits by 
experience, must become a much more skilful prac- 
titioner. How many persons apply a poultice to an 
ulcer with a tolerable certainty of improving it, 
without ever knowing or caring for the rationale 
of the effect ! 

By studying the operations of nature we are led 
to imitate by analogy. Independently of the re- 
gulation of temperature, the usual benefit derived 
from a poultice is that of preventing premature 
scabbing, by the soft moisture assisting the pus 
to protect the granulations. The German water- 
dressing has much the advantage over the poultice : 
the piece of lint dipped in water is lighter than 
the poultice ; the oiled silk over all retains the 
moisture ; and the whole does not spoil the sound 
skin, as the poultice often does. If poultices be 
too long applied, proud flesh will form, either 


from a superfluous growth of healthy .granula- 
tions, or of such as are weak and spongy. Exu- 
berant granulations may be checked, either by 
applying an astringent, such as vinegar, nitrate 
of silver, or sulphate of copper, &c, which, by 
constringing the vessels, gives a firmer, smaller 
granulation ; or by merely laying on a piece of 
dry lint, to absorb the coagulable lymph as 
fast as thrown out, thus stop granulation. This 
accounts for dry lint preventing the healing of 
some ulcers, and assisting others, according as 
the granulations require repressing or not; and 
what has been here stated affords an explanation 
why in some cases dressings should be changed 
frequently, in others as seldom as possible. Bayn- 
ton's strapping unites the advantages of keeping 
the granulations moist, with support; but if injudi- 
ciously applied, injury is done by the pressure. Mr. 
J. Scott has clearly pointed out the difference, prac- 
tically, between support and pressure : weakened 
vessels want support, but cannot bear pressure. 

I have above used the term premature scabbing, 
because the crust formed is sometimes of use ; as, 
in the natural process of healing of an ulcer or 
abrasion, the crust sets bounds to the granulations, 
which otherwise might sprout too high. 

The application of dry lint will be enough, with- 
out an astringent, if the proud flesh be merely too 
great a growth of healthy granulations, caused by 
keeping on the poultice too long ; but if the granu- 
lations are also weak, the astringent will be neces- 
sary : this weakness may be known by a livid co- 
lour, and thin, instead of creamy pus ; and if still 


weaker, the granulations will even melt away, and 
the sore reulcerate. Now, an inexperienced per- 
son would suppose that the application of nitrate 
of silver (lunar caustic) or vinegar would increase 
the pain ; but it is well known that, though they 
produce momentary smarting, especially if applied 
undiluted, this soon subsides ; so that a person will 
fall asleep shortly after the application of nitrate 
of silver to an ulcer, which had banished rest for 
several days and nights by its morbid sensibility. 
The beneficial effect may be thus explained, — the 
nerves of the part having become inflamed, and 
their vessels partaking of the debility of those in 
the surrounding tissues ; the astringent diminishes 
the inflammation in the nerves, and thus removes 
their morbid sensibility, bringing them to the state 
of the nerves in a healthy granulating part, in which 
those below the granulations are sensitive, but not 
more so than natural. Oil of turpentine applied 
to a burn acts on the same principle of bringing 
the nerves to the state of those in a healthy part, 
not merely by astringency, but also by eliciting 
more nervous influence in a part whose vital power 
is depressed (p. 30). 

This will aptly illustrate the nature of morbid 
sensibility, usually designated by the vague term 
irritation. It does not occur during the repara- 
tory process (" healthy inflammation"*), the nerves 
not being inflamed ; but " morbid" inflammation 

* Formerly I have sometimes used the term healthy inflamma- 
tion as synonymous with reparatory process, in compliance with 
custom ; but it is wrong : inflammation under all circumstances is 
disease, being, in fact, the injured state which precedes the repara- 
tory process. 


(as it is called when the reparatory process is inter- 
rupted) involves the nerves. A considerable degree 
of pain may exist during even the healthy repara- 
tion of injury, when the healthy nerves are exposed 
and hurt ; but there will be more disturbance and 
loss of sleep, with perhaps less pain, if, from the 
nerves themselves becoming inflamed,* morbid sen- 
sibility arises, either locally, or in the nervous cen- 
tres, in consequence of the lesion of the nerve being 
communicated to them, whether the lesion be in 
the sensitive or organic filaments : in the latter 
case, there can be no evidence of morbid sensibility 
until the lesion is propagated to the nervous centre ; 
as in tetanus, arising after a cut has healed almost 
by the first intention, without pain in the cicatrix ; 
or convulsions from worms in the intestines, which 
have caused no pain. 

By a process analogous to granulation, coagu- 
lable lymph, exuded in consequence of inflamma- 
tion between serous membranes, sometimes be- 
comes organised, and forms adhesions. 

In mucous membrane the change is very rapid 
from health to disease : by a slight alteration of 
the action of the capillary arteries, which secrete 
a mild fluid to lubricate and protect the surface, it 
becomes either dry, or a thin saline fluid is poured 
out, which, so far from protecting the parts, irritates 
them and others with which it comes in contact. 
Again; after the mucous membrane has been 
throwing out the fluid just described (as in catarrh), 
the thickening of the discharge, and its becoming 

* I know no other term by which to express their lesion. 


bland and opaque, whitish, (in other words ap- 
proaching to, and in some instances forming actual 
pus,) is the simple reparatory or restorative pro- 
cess ; and we know that various mucous mem- 
branes, whilst inflamed, — the urethra, for instance, 
— throw out an ichorous fluid, which becomes true 
bland pus as the reparatory process proceeds ; and 
it is the same with respect to the schneiderian 

Thus, we see, we can have both coagulable 
lymph and pus, without ulceration. Sometimes 
coagulable lymph oozes from the capillaries of 
mucous surfaces, and concretes, forming what are 
called false membranes, as in croup. Similar for- 
mations are also sometimes passed from the bowels, 
which have been mistaken for a separation of the 
lining membrane. They are of a tubular form, 
different from the long vermiform evacuations of 
merely condensed mucus which are sometimes 
passed from them. Hunter has pointed out the 
close analogy between the throwing out of coagu- 
lable lymph in (I say after) inflammation, and 
the formation of the first lining membrane of the 
gravid uterus ; and sometimes even a similar false 
membrane forms in the unimpregnated uterus, as 
occurs in cases both of dysmenorrhea and menor- 
rhagia, besides those which form in the vagina, of a 
larger size and different shape. Thus the same 
coagulable lymph, so useful for the purpose of re- 
pairing damage or continuing the species, some- 
times kills — as in croup, by blocking up the wind- 
pipe ; or produces blindness, by rendering the 
cornea opaque ; or glues the intestines to one 


another, after peritoneal inflammation. And we 
have not only these false membranes, as they are 
called, thrown out on serous surfaces, but also pus, 
without breach of surface. The operations of na- 
ture are uniform and simple, — the reparatory pro- 
cess is uniform and simple. The throwing out of 
the coagulable lymph, in these cases, is equivalent 
to its being thrown out to effect union by first in- 
tention, or granulations, though, from the locality 
(the cornea, windpipe, &c), it becomes inconve- 
nient, or even destructive. 

If by a blow or other injury, as by caustic, or 
by any inflammation, the life of a portion be de- 
stroyed, it gradually decomposes, and separates 
from the living part ; sometimes in the form of 
a discoloured slough, the fluid parts running off 
when the slough is on the surface. The separa- 
tion is effected by decomposition, and not by the 
absorbents of the living part removing a portion of 
the dead parts, as has been asserted : the part at 
the line of separation of a slough of the skin, for 
instance, decomposes most rapidly, from the heat 
and moisture of the surrounding living part ; 
whereas the centre of the slough often dries up, 
like a piece of leather. After the separation of a 
slough on the surface of the body, an open wound 
is left, which, if the reparatory process go on na- 
turally, will be filled up by granulation, as already 
explained. If a smooth hard substance be laid in 
the wound (as a pea or bean to keep open an 
issue), it prevents the formation of granulations ; 
but as the reparatory process or effort nevertheless 
goes on, pus is secreted from the open capillaries, 


and as soon as the hard substance is taken away, 
the formation of granulations will commence. Here, 
again, we must not confound the reparatory pro- 
cess with inflammation : a properly managed issue 
is not in a state of inflammation ; on the contrary, 
it is well known that if it become inflamed, the pea 
must be taken out for a while to ease it, or the part 
will become swelled, red, and painful ; and either 
proud flesh will form, as before explained, or ulcer- 
ation take place. 

Ulceration is the death of successive layers or 
minute portions of an open wound, of whatever 
dimensions, the solution of continuity having been 
effected either by spontaneous inflammation and 
decomposition, or by external injury ; and the 
matter which successively dies in an ulcer is not 
separated from the living part nor taken away by 
the absorbents, as has been generally asserted, but 
decomposes and runs off. Again ; an ulcer is not 
necessarily in a state of inflammation ; for, on the 
contrary, whilst healing, it is in a state of repa- 
ration ; and any renewal of inflammation causes 
enlargement — fresh ulceration. There is a little 
apparent contradiction in this statement, from the 
word ulcer (ulcus) signifying simply an open wound 
which has been formed by other means, as w»ell as 
by the process of ulceration, or ulcerating inflam- 
mation ; but I repeat that, though the process of 
ulcerating is ulcerative inflammation, yet in the 
resulting wound when once formed there is not 
necessarily inflammation any longer existing ; and 
it is, on the contrary, by carefully warding off in- 
flammation that the surgeon cures it. 



An ulcer, therefore, is not necessarily in a state 
of inflammation ; it is the space left by the destruc- 
tion of a part by inflammation : but if the constitu- 
tion be in a natural state, and the ulcer not influ- 
enced by any morbid poison, it goes on granulating 
and healing. If, instead, inflammation be renewed 
in it, each renewal may cause fresh loss of substance, 
and the ulcer become what is called phagedenic. 

When the whole part, killed by inflammation, 
separates at once, instead of gradually dissolving 
away, it is called a slough ; and if this slough 
takes place by spontaneous inflammation, it is 


A slough may be produced by caustic, then called 
an eschar ; or by chemical poisons, as I have seen 
the whole lining of the oesophagus slough away at 
once in a patient who had swallowed nitric acid. 

When I say that the absorbents do not effect 
the separation of a slough, I do not deny that they 
may, and do, nevertheless take up some of the de- 
composed matter ; for we know that on the death 
of a part which is not superficial, and when, as 
under the skin, the dead matter, being confined, 
cannot run off, the absorbents will often by degrees 
convey it all away ; but in the case of a caustic eschar, 
or a gangrenous slough, it is decomposition, not 
the absorbents, which effects the separation. When 
any injury, from a blow or inflammation, is suffi- 
cient to cause death of a portion deeper seated 
below the skin, the decomposed matter can be 
carried off by the absorbents and (venous) capil- 
laries, as we see in the case of an ecchymosis of 
extravasated blood ; but in general, the reparatory 


process causing the secretion of pus, suppuration, 
an abscess, takes place. Here, again, I must ad- 
vert to the incorrectness of language ordinarily 
used : it is said that, when inflammation exists, it 
is of consequence to prevent suppuration. Now, 
what is to be prevented is, the death of any por- 
tion ; if that take place, the suppuration is merely 
a matter of course, as a part of the reparatory pro- 
cess. After what I have stated, it is scarcely neces- 
sary to add, that I do not admit of the explanation 
of pus being formed by the breaking down and 
liquefying of coagulable lymph, as asserted by 
Laennec, in speaking of empyema ; nor the expla- 
nations of Dupuytren and others, of part of the 
sloughs of abscesses dissolving into pus. 

The cavity is lined more or less with coagulable 
lymph, analogous to the granulations and false 
membranes and adhesions above spoken of. This 
lines the cyst, as it is called, of the abscess, which 
is merely the cellular tissue of the part stretched 
upon the contained pus, and which does not set 
bounds to the abscess, but passively depends upon 
the quantity effused into it. It is the extent of the 
inflammation which in the first instance decides the 
size of the abscess ; and when the inflammation is 
diffused or ramifies, we have diffused or ramified 
abscess, as from diffused cellular inflammation. 
Though it has been stated by high authority, 
that " inflammation is the means by which local 
injuries are repaired, and may be considered as the 
restorative principle," I contend that it is no such 
thing ; but a state of disease ; or else, why speak of 
remedies for it ? And, indeed, in applying them, it 


is of great consequence to know when to stop ; for 
the period of inflammation is often very short ; and 
unless the practitioner knows when it has ceased, 
he may do much mischief by interfering with the 
natural reparatory process. The period of inflam- 
mation of the pleura or peritoneum is often so 
brief, that even destruction of tissue of which a 
patient will inevitably die may have been effected, 
though the inflammation had not lasted above three 
or four hours, as we see occasionally in peritonitis 
and pleurisy, whether idiopathic or from wounds. 

For example ; a youth, after being exposed to 
severe cold, complained, for a few hours only, of 
sharp pain in the abdomen, but became feverish, with 
sickness and constipation. He did not apply for 
advice for two or three days, at which time he made 
no complaint of pain in the abdomen even upon 
moderate pressure, except across the hypochondria, 
where pressure produced some uneasiness. He 
died in about a fortnight, though judiciously treated 
for peritonitis by his medical attendant. On exami- 
nation, all the intestines were found glued together 
by coagulable lymph, and some pus was effused in 
the cavity of the abdomen. 

The practitioner will do harm if he does not 
withhold or relax antiphlogistic treatment (not only 
bleeding, but such medicines as tartar emetic, pur- 
gatives, digitalis, colchicum, &c.) as soon as inflam- 
mation is subdued. I have seen a patient in pleu- 
risy, with extensive pleuritic effusion in one side, 
whose life had been saved by active and judicious 
bleeding, and other antiphlogistic means; but who 
afterwards nearly sunk in consequence of the me- 


dical attendants persevering with purgative and 
other antiphlogistic medicines after the inflamma- 
tion was quite subdued. This they did on account 
of that uneasiness in the parts which was only extra 
sensibility (tenderness, as in a bruised part), in 
consequence of the lesion produced by the severe 
inflammation, and which uneasiness naturally 
remained in a certain degree even for months 

On the other hand, in many protracted cases of 
disease, when the patient feels scarcely ill enough 
to apply for medical advice, we find some latent in- 
flammation, requiring active and decided antiphlo- 
gistic treatment, which may surprise the patient, 
but of which he soon feels the benefit. 

A distinguished writer on inflammation asserts, 
that the "adhesive inflammation which precedes 
the act of ulcerative absorption obliterates the ves- 
sels," so that there is no escape of blood. This, as 
an enumeration of phenomena, is true, but is no 
more than a mode of enumerating phases : as a 
rationale of the process, it is incorrect ; there is no 
such thing as adhesive inflammation — the inflamma- 
tion is that which destroys the life of the part, 
whereupon the separation of the dead portion takes 
place ; which has been erroneously attributed to 
the absorbents. The reparatory (adhesive) process, 
which is intermediate, by its lymph stops the 
vessels, so as to prevent haemorrhage, and subse- 
quently produces granulation and suppuration, as 
before explained. In fact, the succession of events 
is as follows : inflammation, death of part ; repara- 
tory {adhesive) process, effusion of lymph closing 


vessels ; then ulceration, decomposition and separa- 
tion of dead parts. Thus I can account for bone, 
tendon, cellular tissue, and other parts, dying and 
gradually coming away dissolved, or in shreds and 
fragments; but the explanation of their removal 
by the absorbents, nibbling them across, as it were, 
is neither intelligible nor credible. Again; the 
term ulceration is used by authors most contradic- 
torily ; as, for instance, besides its true meaning of 
eroding, we have the expression " the process of 
ulceration, by which the surface is restored :" this 
anomaly arises from the misuse of the term 
(healthy) inflammation. 

It may be asked, how it happens, if the effusion 
of lymph into the cellular tissue be not a part of 
inflammation, that it occurs as one of the pheno- 
mena of erysipelas, and also upon inflammation of 
the cornea or iris, when, instead of deserving to be 
named a part of the reparatory process, it obstructs 
their functions. In erysipelas sufficiently severe to 
cause lymph to be effused, the desquamation is evi- 
dence of solution of continuity of the capillaries ; 
hence the necessity for the reparatory process, viz. 
the effusion of lymph. We may fairly deduce, by 
analogy, that there is likewise solution of continuity 
of the capillaries in the cellular substance beneath. 
The moment this solution of continuity of capil- 
laries — the giving way from the degree of inflam- 
mation — takes place, lymph is effused ; and its use 
is evident, viz. to reunite the breach, as even in 
cases of reparation of an incised wound. When 
the cornea is wounded, we see that the effusion 
takes place, to reunite the capillaries ; in like man- 


ner, when the capillaries give way from inflamma- 
tion, in one or more of the layers of which the cor- 
nea is composed, without breach of surface, lymph 
is effused for the reparation of damage. Had the 
inflammation been superficial, the giving way of the 
capillaries would have been evinced by ulceration. 

When a part receives a blow of a certain force, 
there is an extravasation of blood from the capil- 
lary arteries, or an effusion of lymph, which causes 
swelling of the part. In this instance healthy capil- 
laries are compelled by force to allow their con- 
tents to escape, which are afterwards gradually 
removed by the absorbents. In disease the process 
is similar ; in erysipelas, lymph and serum are ef- 
fused, causing swelling, which are re-absorbed as 
the patient recovers : in dropsy nearly the same 
takes place. 

By savine or cantharides ointment we can pro- 
duce an inflammation — such a relaxation and de- 
bility of the capillaries of a part, that they break 
away from the adjacent sound parts, by which 
means warts are thrown off; and this, as regards 
the mode of separation, is analogous to the rising 
of the cuticle from a common blister. These phe- 
nomena have usually been wrongly attributed to 
the savine and cantharides producing "a higher 
degree of action of the vessels than the parts could 
bear," which is altogether irreconcilable witji the 
true physiology of vascular action (see p. 9 et 

The cicatrix after a wart, resembling the cicatrix 
of a pit of small-pox, is sometimes permanently 


visible, but not always so; as the cicatrix of a 
small-pox spot is sometimes not a permanent mark, 
or, in other words, small-pox does not always 
pit. The reason of this is, that the small-pox 
vesicle does not always suppurate, though it has 
incorrectly received the name of pustule : it is na- 
turally only a vesicle filled with serous fluid, which 
turns whitish and opaque, like pus ; but true pus is 
not formed, except on the surface of membranes, un- 
less the inflammation has been sufficiently great to 
cause that lesion of the capillaries which requires 
effusion of lymph for their cure, equivalent to gra- 
nulation and suppuration ; but, of course, when 
this takes place in a mucous membrane, the mois- 
ture in general prevents the granulating lymph from 
remaining or forming a coating; so that we seldom 
see false membrane on mucous surfaces, the pus 
only being perceived. Fortunately croup is com- 
paratively a rare disease ; but I have known false 
membrane form even in the urethra — at least small 
tubes of coagulable lymph, which I judged to be 
such. Again : we have, after the same degree of 
lesion, the restorative process sometimes throwing 
out lymph, equivalent to granulation, or rather to 
union by the first intention, without pus ; as may 
frequently be seen upon the surface of the rete 
mucosum, the lymph immediately drying into cu- 
ticle, .after a slight abrasion, or a common blister, 
when the cuticle is often restored without suppura- 
tion ; but sometimes the skin is injured, and pus is 
formed during the necessary process of repair. 
Sometimes, after a blister, even when the skin is 


not injured enough to require suppuration, we see 
a superfluous quantity of the lymph which forms 
cuticle thrown out with the appearance of jelly. 

The small-pox eruption, as just mentioned, is 
only a vesicle, though a reticulated one, being an 
aggregate of minute vesicles formed in succession, 
precisely like the vaccine. The vaccine always in 
the end pits, as there is loss of substance of the 
rete mucosum, owing to the intensity of the inflam- 
mation; but the chicken-pox, which is a more 
simple vesicle, and of shorter duration, does not 
always pit. The cause of the peculiar depression 
in the centre of the vaccine and small-pox vesicles 
is this : each eruption first forms in a point, and 
that point, having gone through its inflammation 
before those that follow around it, is elevated on a 
smaller scale, and its coagulable lymph begins to 
dry up whilst the circumference is fresh and swol- 
len. I have heard the vaccine central dark spot 
attributed to the cicatrix of the lancet-puncture, 
and the variolous spot to the binding down by a 
sebaceous duct : but the lancet-puncture heals by 
first intention, before the specific inflammation be- 
gins ; and there are many more than one sebace- 
ous duct in the space of either a vaccine or vario- 
lous vesicle. 

The effect of inflammation, as is evident from 
its proximate cause (relaxation of capillaries), is to 
soften the tissue in which it takes place. An 
inflamed part may feel hard on account of tension ; 
but when cut into, the inflamed tissue will be found 

Inflammation as hitherto considered is what is 
called acute, wherein either resolution or destruc- 


tion of 'parts soon takes place — cita mors venit, aut 
victoria Iceta. Chronic inflammation is that in 
which the cause of the inflammation remains, pro- 
ducing reiterated lesion, followed by continual 
efforts of the reparatory process in depositing co^ 
agulable lymph, which sometimes becomes orga- 
nised and produces actual hardness, as in strumous 
and other tumours, syphilitic nodes and warts, 
chronic hepatitis, &c. ; sometimes a persisting open 
ulcer, as a chancre, in which the reparatory pro- 
cess goes on, and by depositing lymph thickens the 
edges, whilst the continued inflammation keeps the 
ulcer open by the successive death of minute por- 
tions ; or, if it be not strong enough to produce 
death of portions, so as to keep the part in a state 
of open ulcer, it still renews enough of inflamma- 
tion to prevent healing — that is, the organisation 
of the cicatrix, which therefore becomes a scab — 
sometimes single, constituting a scale, as in the 
coppery eruption ; sometimes in successive layers, 
as in rupia; sometimes in clusters after pustules, 
as on the face. 

It is thus that a morbid poison not only inflicts 
the injury, but, by adhering in the tissue or consti- 
tution, perpetuates it till expelled by some remedy. 
This, however, is but an expression or descrip- 
tion of phenomena : I must indulge my propensity 
of searching for proximate causes, and would pre- 
fer any tolerable analogy to none at all. 

The process of fermentation affords an analogy. 
A little leaven leaveneth the whole lump : a most 
minute portion of small-pox virus, on the point of 
a needle, produces an inflammation similar to that 


from which it was taken. What is this inflamma- 
tion bnt chemical decomposition ? What else is 
fermentation ? This virus may be absorbed and 
circulated, as has been hitherto supposed ; or it 
may produce its effect by some chemical, and con- 
sequently electric or galvanic action, positive or ne- 
gative, on the nervous tissue, constituting a morbid 
sensibility, which is propagated to the whole sys- 
tem : — this is evinced by racking pains in the spinal 
cord, brain, &c., producing languor, convulsions, 
&c. &c, with disturbance of all the functions. 

All this passes off, we know, in a definite time, 
as the dough ceases to rise when all the par- 
ticles inflamed by the leaven have gone through 
their process of decomposition. So ends small- 
pox, measles, scarlatina, typhus, plague, synocha 
petechialis, &c. ; the leavens of which are either 
communicated by contact or carried through the 
air to the lungs, &c. 

Lues is different ; and here I must resort again 
to analogy. Its destructive decomposition is of a 
different kind — of a slower, more permanent nature, 
— as much unknown to us, though we know the 
phenomena and products, as that of the panary or 
acetous fermentation. As the acetous fermenta- 
tion is less violent, though more permanent, than 
the panary or vinous, so the syphilitic decomposi- 
tion (inflammation) is gradual, but steadily per- 
vades the system if unchecked by remedies. 

I cannot help here hazarding a speculation upon 
hydrophobia ; namely, that it is a leaven which 
poisons the nervous system, takes a considerable 
time to ferment, and will eventually be remedied 


by some medicine which conquers neuritis — per- 
haps arsenic — perhaps some narcotic. My own 
inclination would be to try as much arsenic as the 
constitution would bear, combined with plenty of 
opium, which always enables the patient to take 
more arsenic than he could without it. I have 
found this to be the case in old cases of ague and 
dysentery, which I have cured by the combination ; 
indeed it is also proved by the efficacy of opium as 
an antidote to arsenic* 

We have not yet obtained a cure for cancer 
constitutionally ; but, aided by the investigations 
of Kiernan, Muller, Ure, and other pathologists, 
I think we shall arrive at it {Med. Gaz., May and 
Dec. 1836.) We have also still to seek the remedy 
for tubercles. Notwithstanding the exertions of An- 
dral, Carswell, Louis, &c, we have not yet arrived 
at their true pathology ; and until that is accom- 

* It is not very uncommon, on patients being brought to the 
hospital in consequence of having taken poison, to find that, 
thinking to make assurance doubly sure by taking arsenic and 
laudanum together, they have saved their lives. In an experience 
of many years, I have always found these cases do best ; and 
many patients who had taken arsenic (arsenious acid), we have 
recovered by laudanum and calcined magnesia freely adminis- 
tered ; making use, according to circumstances, of the stomach- 
pump, leeches, and other means not necessary to be enumerated 
here. If I am not mistaken, a Mr. Hunt was the first to publish 
this useful plan of treatment. The pain (morbid sensibility), 
independent of inflammation, would kill, if not relieved by opium, 
as I have spoken of elsewhere in the instance of gout in the 
stomach. I must add here, for students, that gout of the stomach 
is almost wholly neuritis ; but that in poisoning by arsenic there 
is, besides neuritis, considerable inflammation of the capillaries of 
the membrane. 



plished, it is only some lucky empirical chance that 
can help us. The treatment of the latter which I 
have found most useful is that adapted to scrofula. 
Sometimes tumours are formed in consequence 
of blows, coagulable lymph being effused, and by 
the process already described, analogous to granu- 
lation, becoming vascular and organised (possessed 
of vitality), a part of the animal, and not remov- 
able by the absorbents, which only take up unor- 
ganised, or in other words, dead matter. Some 
of these tumours remain unaltered ; others by 
their presence keep up an inflammation, in con- 
sequence of which the capillaries go on deposit- 
ing more and more by necessarily reiterated re- 
paratory efforts, and so adding to the tumour, 
which thereby is increased, until it is removed by 
remedies or operation, or exhausts the animal and 
destroys life. Now, as was mentioned in other 
cases, that which arises here in consequence of 
accidental injury, sometimes also takes place as 
the effect of disease : tumours form spontaneously, 
either with or without feverish accompaniment, and 
sometimes disappear again by what is called reso- 
lution, that is, cessation of the inflammation, and 
subsequent re-absorption ; sometimes they suppu- 
rate, forming abscess ; sometimes remain indolent ; 
at other times remain and grow larger, or grow 
larger and ulcerate at the same time, as in cancer- 
ous and other malignant diseases. Tumours are 
modified by the part they occupy and the constitu- 
tion of the person: if the substance injured be fat, 
the arteries there, being depositors of fat, make 
a fatty tumour ; if it be periosteum, bony ; if a 


highly vascular part, a vascular tumour. The 
tough bands which traverse fatty and other tu- 
mours are made by arteries, which in a healthy 
state would have to support membranous, cellular, 
or ligamentous tissues. A tumour of a lymphatic 
gland, or other part, in that debilitated, relaxed 
constitution called strumous, or scrofulous, will 
become so : and in a cancerous constitution tainted 
by disease, cancerous tumours will form in any 
and every part, as has been ably demonstrated by 
Kiernan. The same may be said of tubercular 
disease, which is totally distinct from common in- 

The same process which repairs, if induced 
morbidly, produces diseased growths, such as bony 
tumours from syphilitic or other inflammation of 
the membranes of the bones. When there is tooth- 
ache from caries, the injury is in a part which can- 
not be repaired, as being destitute of membrane ; 
hence the inflammation excited in the sound part 
produces only a useless deposit, as we see some- 
times evinced by morbid growth at the point of the 
root, but no repair of the mischief, so that the 
tooth must be removed altogether. The arteries 
of the periosteum are always ready to deposit bone ; 
whenever, from accident or disease, its vessels be- 
come distended (with or without rupture and ex- 
travasation), and the part spongy, as in nodes, there 
is, if not stagnation, a sufficient retardation of the 
blood to allow of crystallisation of bony matter. 
The arteries cease to deposit when the spaces 
made by accident or disease are filled ; if there be 
not enough of bone deposited to unite a broken 


limb, or if the consolidation has been prevented by 
motion of the parts, the surgeon often rubs the 
broken ends against each other, not for any effect 
upon the bone, but the real use of this expedient 
is to produce fresh laceration of the soft parts, so 
as to allow of renewed deposition of bony matter, 
and to make fresh spaces for its reception : here 
though inflammation be excited, as a necessary 
consequence of the violence resorted to, and it has 
usually been said that the intention was to produce 
inflammation, if the space for fresh callus could 
be made without it, it would be all the better ; and, 
in fact, on the other hand, it is well known that 
much inflammation in a fractured limb retards the 
formation of callus, so that leeches and other means 
are used to moderate it. 

If the absorbents cannot take up matter which 
is organised, it may be asked how they remove 
tumours ? The organisation of a tumour is but im- 
perfect, and it is a burden on the previously exist- 
ing arteries, in addition to their originally allotted 
task : if these arteries have been enlarged in size 
(for we know arteries can grow larger) in conse- 
quence of the inflammation which gave rise to the 
tumour, they will go on to support it ; at other 
times, and most frequently, when the inflammation 
subsides, they resume their natural size, and starve 
the tumour, the constituents of which will, when 
thus deprived of support, become decomposed, un- 
organised, and thus amenable to the absorbents : 
on the other hand, the tumour may have been too 
well organised to give way, and so continue a com- 
paratively indolent life, after all inflammation has 



subsided, but producing neither pain nor inconve- 
nience, unless a blow or other cause renew inflam- 
mation. Now, if the efforts of nature do not re- 
move the tumour, we may diminish it by remedial 

The simplest is pressure on the part, by keep- 
ing nourishment from entering its vessels,* as 
when a piece of sheet-lead is bound down upon 
it, &c. 

Pressure so gentle as not to compress, but merely 
by affording support to inflamed and distended ves- 
sels, at first, to stop the inflammation ; after which, 
stronger pressure may be resorted to without pro- 
ducing pain. 

Cold will cause vessels to shrink, as cold lo- 
tions, &c, constantly applied, where pressure could 
not be borne on account of its producing pain. 

Daily, or at least often-repeated, abstraction of 
blood by leeches, &c. from the part, taking care not 
to undermine the constitution by taking too much. 

Artificial discharge, with counter-irritation, as 
by issues, blisters, the tartar emetic, and iodine 
ointments, &c. 

By medicines, such as mercury, iodine, &c, 
which have an effect on the arteries themselves, 
directly or through their nerves, so as to make 
the inflamed capillaries contract independently of 

* It is by this effect of pressure that a tooth may be made to 
change its place, as when children's teeth are set straight by a 
dentist, and which has been asserted to be effected by the absorb- 
ents. It is the pressure of the tooth on the vessels in one side of 
the socket which makes it disorganise ; and then the absorbents 
may take Up the inorganic particles, and the vessels on the other 
side of the socket fill up the space left (see p. 9). 


the consideration of the vis a tergo (state of the 
heart's action), or quantity of circulating fluid ; 
for this may be necessary even when the circula- 
tion is very weak ; as in some cases, inflammation 
goes on with a most debilitated constitution and 
weak pulse :* it is only the debility approaching to 
a dying state that will prevent a blister from rising, 
when the poison of cantharides has relaxed the 
vessels : hence it is plain, that it must be an enor- 
mous loss of blood which could prevent a blister 
from rising; which shews that the proximate cause 
of the inflammation is in the vessels of the part, and 
not in the injecting force. This will explain to the 
pupil, who has seen how much venesection has 
relieved inflammation from fractured ribs, that 
he cannot always " knock down"f inflammation by 

* This is by some called passive inflammation, in contradis- 
tinction to that which occurs in a strong constitution ; but inflam- 
mation is always the same debility of capillaries. Let us call things 
by their own names, and speak of the active or passive state of the 
constitution as indicating remedies. 

f I consider the opinion wrong which Dr. M. Hall gives in 
allusion to certain cases of inflammation from accidents which 
terminated fatally, under the treatment of other practitioners. 
He says that, had they been real inflammation, they would have 
borne the depletion (see his lecture, Lancet, Nov. 4, 1837, 
p. 186). Now, I think they would not; for I am convinced 
that, where cases of inflammation, whether idiopathic or from 
accident, will not yield to bleeding within rational bounds, as- 
sisted by antiphlogistic medicines, they must terminate fatally, 
either by the violence of the disease, or by the unavoidable 
extent of the depletion. I must also observe, that though he, 
being experienced, may know when to stop, I should fear his 
pupils might be led, in pleurisy, &c., to carry bleeding to dan- 
gerous lengths; as I was once called to see a medical pupil just 
before his dissolution, who, after hearing the lecture of a popular 
teacher on the subject of " knocking down" enteritis by deple- 



venesection alone ; though free venesection in the 
beginning is of the utmost consequence. For, 
on the contrary, though the copious bleedings at 

tion, had made his fellow- student bleed him till he sank never to 
rise. Dr. Hall says his medical friend (one of the cases he there 
alludes to — pleuritic inflammation produced by fractured ribs) lost 
about eight pints of blood within four days ; and yet he declares 
that had it been pleurisy, he might have lost twice as much with 
impunity and safety. I think, however, no man could lose fifteen 
or sixteen pints (two gallons) of blood in three or four days with 
" impunity and safety." This is what he calls establishing a dis- 
tinction between irritation and inflammation : truly, it is a strongly 
marked distinction — without a difference ; for it was, in fact, a 
" mixed case." With respect to the man who died of fractured 
ribs with wounded lung, in Bartholomew's hospital, quoted by 
him, I must express an opinion contrary to that of Dr. Hall, who 
brings forward the case as one of irritation, in which the man died 
of exhaustion from a degree of bleeding which he could have 
borne had the case been inflammation. I cannot acknowledge 
the distinction Dr. Hall has here made between inflammation and 
irritation, as I consider inflammation of the pleura or lungs, 
though produced by broken ribs, still genuine inflammation, and 
not irritation, or what I call morbid sensibility. By the second case 
alluded to at page 52, I have shewn when inflammation abates, 
and irritation (morbid sensibility) predominates. But because 
the last bleeding in the cases of traumatic pleurisy just noticed 
accelerated the fatal termination, Dr. Hall seems to doubt the 
necessity for free venesection in similar ones ; as if they had been 
cases of " irritation " from the commencement, whereas serious 
inflammation existed. Indeed, he says (Principles of Theory and 
Practice, 1837, p. 355), " cases of fractured ribs do not bear the 
loss of blood like those of inflammation." Of course the mere 
fractured bones do not require it ; but I contend, on the contrary, 
that pleurisy from broken ribs requires the same antiphlogistic 
treatment as idiopathic pleurisy; at the same time making due 
allowance for inflammation or morbid sensibility being kept up by 
mechanical irritation, as by fractures elsewhere. I formerly wit- 
nessed much surgical practice, and I have seen patients certainly 
sometimes bled too freely for traumatic pleurisy ; but I have known 


first relieve the patient at the time when he can 
scarcely draw his breath, yet subsequently, pain, 
and even difficulty of breathing, will return, which 
cannot be relieved by repetitions of the bleeding, 
even if that were not inadmissible from the danger 
of sinking by loss of blood ; and when pain and 
dyspnoea are urgent, we must try what can be 
done with antimony, ipecacuanha, mercury, opium, 
digitalis, &c, varied and modified according as there 
are more or fewer febrile symptoms accompanying. 
I should say, that it is seldom necessary to abstract 
to the amount of five or six pints of blood within as 
many days, if active medicinal treatment be adopted 
to coincide with the bleeding. 

We see that solutions of metallic salts, such as 
nitrate of silver, tartar emetic,* acetate of lead, 

the same error committed in medical cases of idiopathic pleurisy. 
This, however, was not from ignorance of " diagnosis" in either ; it 
was from want of knowing how much the powers of the constitution 
could bear; there was inflammation in all the cases, and "irritation" 
also. Much as I approve of what he has written on the physio- 
logy and pathology of the nervous system, on the " mimoses," 
" reflex function," &c, I cannot tolerate his perversion of the 
term " diagnosis," " by blood-letting ;" for, notwithstanding the 
one sentence in italics placed to meet anticipated objections, that 
expression is calculated to puzzle, if not mislead, his junior readers. 
Diagnosis has always been understood to mean the distinction 
made between diseases for the very necessary purpose of arranging 
the treatment. In my opinion, before such a decided step as 
bleeding is adopted, the physician ought to have made up his 
mind as to what is the nature of the disease. In the previous 
editions of this work I have adduced examples (which will ap- 
pear in their proper places) of pure " irritation," that do not bear, 
or rather are not benefited by, depletion. 

* A solution of antim. tartar, may be used with great advan- 
tage as a lotion to some cutaneous eruptions. 


bichloride of mercury, &c, and some acrid vegeta- 
bles, such as mezereon, &c, act on the capillaries 
as astringents ; but each of these, when too strong, 
produces a contrary effect, viz. inflammation and 
relaxation. We know that substances applied to 
the surface of the primae viae, or skin, are absorbed 
and carried into the circulation ; and we judge that 
in this way these metallic salts, oxydes, &c., are 
carried to the capillaries of diseased parts, so as 
to act like astringents, and strengthen and cure. 
We know too that they are adapted to different 
cases. Antimony, which produces sickness and 
lowers the pulse, besides its local effect on the capil- 
laries, when it reaches them through the circulation, 
is suited to, and resorted to in, acute diseases, such 
as inflammatory fevers, whether idiopathic or from 
injuries. Thus, we can account for the efficacy of 
antimony in such a disease as scarlatina, by its 
diminishing inflammation in the superficial capil- 
laries of the skin, fauces, &c, which have been 
relaxed by the morbid poison, and at the same 
time by reducing the power of the circulation 
when it is too strong, if administered so as to pro- 
duce slight sickness or nausea : or if there be a low 
state of fever not requiring reduction of the pulse, 
the antimony may be given in small repeated 
doses, so as to circulate to the capillaries without 
depressing the system. Mercury, which has not 
this nauseating property, acts less on the pulse 
than antimony, but perhaps even more upon the 
capillaries, when circulated to them ; hence it is 
oftener used in chronic cases, both syphilitic and 
others, besides being much employed in acute 


inflammation, pleurisy, peripneumony, peritonitis, 
&c. This affords a rationale of these remedies 
curing inflammations where there is no indication 
for depletory or common antiphlogistic means ; for 
which mode of cure the vague term, -' equalising 
the circulation," has been adopted ; but it is erro- 
neous, as the circulation cannot be unequal : it 
may be irregular, stronger or weaker, quicker or 
slower ; but in either case the blood must be sent 
or circulated equally to every part of the body, as 
it passes at first from the heart through a single 
canal, the aorta ; as stated when speaking of what 
has been called determination of blood (p. 31). 

Although chemists cannot detect either mer- 
cury or antimony, administered as remedies, in the 
circulating blood, it alters not my position. It is 
not fair to conclude that the metallic compound 
is not there, because they have been unable to 
detect a quantity of it which bears so minute a 
proportion to the whole mass of fluids of the body. 

We are by no means to draw the conclusion, 
that an affection is not inflammatory, merely be- 
cause it does not yield to depletion. What degree 
of depletion would remove a node, or syphilitic 
iritis, without mercurial or other medicine? What 
would venesection do for rheumatic pains, without 
antimony, colchicum, opium, bark, mercury, and 
other medicines ? Mercury and iodine * remove 

* Iodine is very similar to mercury in its effects on the animal 
economy. The hydriodate of potash is a very manageable and 
good preparation of it. Like mercury, its effects are very variable 
on different constitutions. Some persons cannot bear much more 



morbid growths by starving them, which they 
effect by contracting the capillaries, and not by 
increasing absorption, as is a commonly received 
opinion. It may be said, that the swelling of the 
gums and fauces from mercury is a contradiction 
of this ; but in many of our medical explanations 
we appear to " blow hot and cold." Mercury stops 
inflammation by the same means in one case as it 
produces it in another, — it contracts the capil- 
laries ; so that a healthy part is inflamed and even 
ulcerated by what contracts its nutrient capillaries 
beyond a natural state ; an unhealthy ulcer is 
stopped by what contracts its relaxed capillaries to 
a natural state. Contraction of the vessels, how- 
ever, does not express the immediate cause of the 
sponginess of the gums ; there is, in fact, inflam- 
mation, relaxation, which is the secondary result of 
the contraction ; the excessive contraction occa- 
sioning the loss of contractility, that is, over-action 
causing at last a loss of power ; as cold, which at 
first contracts, will at last destroy the power of 
the capillaries, so that relaxation, amounting to 
inflammation (chilblain) takes place. The sore- 

than one or two grains of the salt three times a day without 
inconvenience, whilst others can take more than ten times that 
quantity. The mode in which it mostly disagrees is by irritating 
the stomach ; it produces a perception of fcetor, and sometimes 
soreness, in the mouth and fauces, and great languor. I have 
been called in to two cases where, in imprudent doses, it had 
produced gastritis, like arsenic, but which was soon relieved by 
leeches and opiates. The bichloride of mercury, or liq. arseni- 
calis, which are so useful in small doses, would do the same in 
excess. The abuse of a remedy is no argument against its use. 


ness * of the membrane of the mouth in ptyalism 
is analogous to chilblain, the cold air, saliva, &c. 
acting upon a membrane whose vessels are in a 
state of extra contractility ; moderate cold, with 
extra contractility, producing the effect of intense 
cold with ordinary contractility. It is thus that 
we have, in the rationale of medical phenomena, 
to refer constantly to the variation of the propor- 
tions of the components of a sum — i. e. the two 
things which contribute to a phenomenon. In the 
foregoing statement, the extra contractility depends 
upon extra sensibility of the nervous part of the 
apparatus — the organic sensibility of Bichat (p. 17) 
— which is diminished, if not lost, when inflamma- 
tion takes place, and the augmentation of which is 
a means of remedying inflammation ; as a cold 
lotion may relieve a chilblain, which is inflamma- 
tion produced by cold, and as cool air relieves 

We see, in a variety of instances, that a remedial 
agent too long or too powerfully applied becomes 
noxious, by exhausting the vitality — in fact, wear- 
ing out or straining the machinery of the organ, so 
that it can no longer answer to the nervous influ- 
ence, whether the organ be capillary tube or any 
other structure ; and sometimes it remains for us 
still to investigate what part of the machinery has 
been injured — the contractile or nervous tissue. 

But, even granting that syphilis or ague might 

* There are persons, as is well known, whose mouths are so 
susceptible to mercury, that they cannot, in the ordinary way, 
take it long enough to cure the diseased capillaries in other parts. 



be cured by low diet, abstraction of blood, and 
other general means, and supposing itch were 
curable thus (which it is not), instead of by sul- 
phur ; the question is not so much as to possibi- 
lity, as expedition, and safety to the constitution : 
what degree of depletion would cure a rheumatism, 
which gives way to doses of colchicum too small 
to cause any sensible evacuation ? just as small 
doses of arsenic will cure cutaneous inflammation, 
that could not be affected by bleeding or other 

It was long before I could account for what 
are called the specific effects of such remedies as 
mercury, arsenic, colchicum, &c. We can under- 
stand thus far, that the membranes, cellular tissue, 
skin, and parts which are very vascular, under 
common inflammation run a rapid course of dis- 
ease, and are relievable by active antiphlogistic 
means; but when parts are attacked by specific 
inflammation, which is produced by a morbid poi- 
son, and which is slow in its progress, or when the 
tissue inflamed is one of dense structure with very 
minute capillaries, depletion, or taking off the vis a 
tergo, has little or no effect on those capillaries ; 
and we are obliged to resort to what have been 
called specific medicines, such as mercury, arsenic, 
&c, which make them contract. Here we are 
supplied with analogies to help us in the prosecu- 
tion of the cure of diseases with other remedies, in 
cases when the so-called specific either fails or dis- 
agrees ; which being ascertained, the specific use 
of the medicine ceases — it ceases, in fact, to be a 
specific. For instance, at one time no remedy was 


known except mercury against the chronic inflam- 
mation produced by the syphilitic poison. Now, 
taking my view of the proximate cause, we should 
deduce, a prio?i, that iodine might cure it, or 
that rigid diet and such remedies as mezereon 
would do so, by their effect on the capillaries; 
which has, in fact, been empirically proved to be 
the case. But it may be said, I have got no farther 
than the empiricism ; on the contrary, I have no 
doubt but that arsenic would answer, but that, 
again, is not a fair example, as it is already used 
empirically in India ; but iron would answer, only, 
not being so powerful, it would require the incon- 
venient adjunct of a rigid diet, as mezereon does. 
Again, I have no doubt that, on principle, colchi- 
cum might be substituted for mezereon ; or anti- 
mony, silver, or copper, for the other chemical 
remedies : gold has been tried, and found to suc- 
ceed. But though it be useful to have other 
means, when we cannot employ the ordinary one, 
we need not resort to a hatchet or a penknife to 
cut bread with, when there is a table-knife at hand ; 
nor have recourse to any thing in preference to 
mercury for the cure of syphilis, from an apprehen- 
sion that it may disagree, because in one in a thou- 
sand or a hundred cases it is found to do so. It is 
better to learn to modify it, by combining opium, 
&c. with it, to correct any inconvenience when it 
occurs; and when, of course, it is necessary to be 
able to bring analogical remedies into play. 

The specific which puzzled me most and latest 
was sulphur for itch ; but now the mystery is satis- 
factorily cleared, and we see why more powerful 


drugs taken internally could not cure it. Its 
cause being a parasitic animalcule, it is easily re- 
moved by rubbing on sulphur, which kills the 
little animal in his lair ; whereas he could not be 
hurt by the remedies that cure those eruptions 
which are a disordered state of the capillaries, and 
which are easily affected by the remedies as they 
circulate through them. Therefore, as there are 
other substances which can kill the animalcule, 
though perhaps none so conveniently as sulphur 
(corrosive sublimate, for instance, might salivate 
before it could cure the itch), one more specific 
is struck off our list. As for colchicum being a 
specific for gout or rheumatism, it is no such 
thing ; there are several equally efficacious means 
of treating either. Again, there is no single spe- 
cific for tic douloureux : cases have been cured 
with liq. arsenicalis, in which iron had failed, and 
vice versa ; and I have cured a case with carbonate 
of iron, combined with galvanism, which I was told 
had held out against all the usual modes of treat- 
ment.* Tic douloureux may also be sometimes 
cured better by quinine, or opium with bark or 
quinine, than by any other medicine ; sometimes 
mercury, &c. &c, are necessary. Bark is no longer 
a specific for ague ; we can cure it with arsenic, 

* Carbonate of iron had, of course, been already employed to a 
large amount; but the disease was kept up evidently by a torpid 
state of the liver, which had resisted mercury and other medicines. 
The cautious repeated application of galvanism to the organ, in 
about a week produced an abundant secretion of good bile, and 
improved the digestion ; after which a perseverance with the iron 
for some time cured the neuralgia. 


and other remedies that cure neuralgia or neu- 
ritis, which ague is in fact. 

In addition to what was formerly stated on 
the subject, I may here observe, that nervous 
influence is elicited in producing nervous actions, 
such as perceptions or thoughts ; organic actions, 
such as those of capillaries, heart, or intestines ; 
and the combination of nervous and organic action 
— voluntary motion. If this expenditure exceed 
the supply, or secretion, by the cineritious part 
of the nervous system, exhaustion is evinced in 
various ways : in health, by sleep ; in disease, by 
delirium, stupor, or death. The heat of fire pro- 
duces a sensation first of pleasure, then, if in- 
creased, of pain : this elicitation of the nervous 
influence does no harm if the person be in health, 
because it is kept up by the apparatus of the brain 
and nervous system which generates it ; but if the 
person be feverish, or the nervous system out of 
order, sitting close to the fire adds to the exhaus- 
tion and debility ; nay, even in health, a lazy in- 
dulgence over the fire produces languor ; and other 
indulgence of nervous sensation produces debility, 
" balnea, vinum, venus," &c. 

To judge by the phenomena, alcohol produces 
sensation by calling forth nervous influence ; its 
presence, like that of fire, exciting a quicker extri- 
cation of it. Here, again, whilst there is health, 
so that the nervous influence is renewed, no harm 
is done ; but, according to the constitution, the 
abuse of wine or spirit produces, sooner or later, an 
exhaustion, and the result is a feverish or irritable 


state, analogous to bodily fatigue, which is pro- 
duced by expenditure of nervous influence in the 
successive discharge of it into the muscles, to keep 
up their action in walking or laborious exercise. 

Sleep is a cessation of that expenditure of ner- 
vous influence which takes place in nervous action, 
such as volition, and other functions of the sen- 
sorium, organic action continuing. The expendi- 
ture of nervous influence going on, under ordinary 
circumstances, quicker than the generation of it, a 
periodical return of sleep is induced. 

As the nervous influence is supplied to all the 
nerves in common, from the so-called nervous 
centres, the expenditure of nervous influence in 
one part usually lessens it in others. Fatigue from 
labour includes a certain exertion of the brain in 
the production of voluntary motion ; but if the 
body and mind be fatigued simultaneously, as when 
a person has to walk much, the mind at the same 
time being anxiously occupied, the expenditure of 
the nervous influence will be more rapid, and the 
exhaustion greater. Again, the expenditure of 
nervous influence in intense study or professional 
business, especially if anxiety be combined, with- 
draws so much of it as to diminish the energy of 
the digestive organs ; and in this way the cares of 
business become the fruitful source of indigestion 
and gout, particularly if, as in great cities, perpe- 
tual feasting add to the labours of the stomach. 

It is well known that digestion produces drow- 
siness and chilliness, by diminishing the energy of 
the brain, and by abstracting the nervous influence 
of the skin. 


It is necessary here to notice the distinction 
between stimulants, sedatives, narcotics, and tonics, 
a great confusion of language and ideas having 
prevailed on these subjects. For instance, any 
medicine which made a person better, without evi- 
dent effect on the bowels, kidneys, &c, was called 
a tonic ; and inasmuch as it restored strength to 
the system, it undoubtedly had a tonic effect. Now 
this is the case so often with wine in debilitated 
habits, that it is no wonder stimulants and tonics 
became almost synonymous ; and the common 
mode formerly of administering bark in wine in- 
creased the error, so that bark was thought stimu- 
lant. We have a difficulty, too, in distinguishing 
the qualities of medicines, from many of them hav- 
ing two principles combined, as will be presently 
pointed out ; we may, however, get very nearly 
pure examples of each — stimulant, sedative, nar- 
cotic, and tonic. 

A stimulant is that which, through the medium 
of the nervous system, increases the action of the 
heart and other organs, by calling forth the nervous 
influence, or by facilitating the extrication of it in 
them ; for example, wine, brandy, and other spirits, 
the product of fermentation. 

A stimulant increases the action of the heart, 
and consequently for a time, by sending more ar- 
terial blood to the brain, besides its own effect on 
the brain when conveyed thither through the circu- 
lation, excites the sensorium to hilarity, if there be 
no latent disease there ; but in too great a quantity 
it produces stupor. Brandy produces stupor by 
excess of stimulus, thereby exhausting nervous in- 


fluence and perception of the brain ; as looking 
at the sun will take away the power of the optic 
nerves by excess of stimulus, and as too great noise 
will cause temporary deafness : though light and 
sounds in moderation yield pleasurable sensations. 
The effects of stimulants are referrible to a two- 
fold operation both upon the brain and spinal mar- 
row, and upon the heart. Each of these systems, 
the nervous and the circulatory, is affected by a 
local and a general operation of the stimulus upon 
their respective centres. The stimulant (brandy, 
for instance), as soon as absorbed and carried into 
the blood, comes into contact with the internal sur- 
face of the heart, upon which organ it acts as an 
excitant locally or by " reflexion," — besides pro- 
bably its influence on the heart by sympathy, 
through the branches of the solar plexus passing 
between the stomach and heart, — and thus ex- 
cites the heart to increased activity ; from thence 
the spirit, mixed with the arterial blood, is propelled 
to the brain, which it excites to a more rapid elimi- 
nation and distribution of the nervous influence. 
Respiration, or the decarbonisation of the blood 
in the lungs, is more perfect ; the function of the 
heart, like that of every other organ, is carried on 
more energetically as regards frequency and force ; 
the nervous centres receive, therefore, a more 
copious supply of arterial blood ; the sensorium, if 
the brain be affected by no latent disease, is excited 
to hilarity ; all impressions upon the nerves are 
perceived by it more acutely ; the generation and 
the flow of ideas are accelerated ; volition is more 
rapid ; all the glandular organs, as well as the skin 


and mucous membrane, secrete more actively ; 
through which, and perhaps by arousing even the 
comparative torpor of the involuntary muscles, as 
of the alimentary canal, digestion, absorption, and 
defecation, are accelerated. These are the effects 
of moderate quantities of stimuli ; in excess, phe- 
nomena the very reverse of many of them succeed: 
the brain is poisoned by the spirit in contact with 
it ; the nervous principle which it contains is ex- 
pended, and the generation and disengagement of 
more is interfered with ; so that the capillaries, 
from the exhaustion of nervous influence, become 
more distensible; the imagination is rendered vapid, 
the perceptions and ideas confused. The brain 
will be overpowered with arterial blood from the 
increased action of the heart, which the stimulants 
have occasioned ; for although arterial blood is the 
source from which the capillaries of the brain pre- 
pare or secrete the nervous principle, over-injection 
diminishes secretion (as in the kidneys, &c.) ; but 
mere increased action of the heart is not sufficient 
to produce the bad effects of over-injection, unless 
the local effect of the spirit upon the brain, as dis- 
tensibility of capillaries, &c, takes place simul- 
taneously. The over-injection will lead to febrile 
excitement, as it is called, the secretions in every 
part being diminished from want of nervous energy 
(besides the over-injection of the glandular organs 
themselves) ; and at length stupor, coma, and even 
fatal apoplexy, may be the result. 

Such are the visible effects of stimulants when 
administered to persons in health {physiological 
effects) ; and similar are those we witness from 


their agency in disease, although modified by the 
malady itself under which the patient labours (pa- 
thological effects). 

A sedative is that which diminishes the action 
of the heart and other organs by repressing the 
nervous influence ; for example, digitalis and green 
tea, the last of which, though called a stimulant by 
some, was long since proved by Dr. E. Perceval to 
have an effect similar to that of digitalis : * green 
tea in excess produces a sense of anxiety and op- 
pression of the chest, with intermitting weak pulse, 
nausea, &c. 

It has been often asserted, that there is no 
such thing as a direct sedative or allayer of action, 
but that the sedative effect was only the secondary 
result of exhaustion from stimulus, arguing from 
the stupid state which comes on in intoxication 
from fermented liquors, and from opium,f which is 
observed to be stimulant in small quantities, before 
enough is taken to produce stupor. It having 
been thus observed that a state of exhaustion suc- 
ceeds intoxication, or any other abuse of stimulus, 
it became adopted as an axiom by many, that there 
could be no sedative effect unless secondary, as 

* The publications of Rush, Rasori, and Tommasini, would, 
I think, satisfy any person that digitalis is a sedative (" contra- 
stimulant "), though, up to this time, not a year passes in which 
the pages of periodicals are not loaded with attempts to prove it 
a stimulant. 

f It must be recollected in practice, that opium contains two 
principles, the narcotic as well as the stimulant. Unluckily, the 
true narcotic part has received the name of morphia, and another 
part narcotine. 


the result of previous excitement ; and I have 
found many who endeavoured to prove that digi- 
talis at first produces a stimulant effect. The only 
apparently good argument, in my opinion, that 
they could bring forward is, that digitalis and other 
sedatives sometimes make the pulse quicker than 
it was before; but every person who has bled a 
few patients must have observed that the pulse 
becomes quicker as the patient grows faint. Mere 
increased frequency of the pulse is not therefore a 
proof, as no person will call blood-letting to syn- 
cope a stimulant. It may, however, be contended, 
that in inflammatory complaints the pulse will be- 
come not only more frequent but harder, that is, 
in fact, stronger, during the administration of digi- 
talis : but this effect is not produced by the digitalis ; 
for if, when the patient does not take enough, a 
few drops only being administered at each dose, or 
bleeding and other remedies being neglected, or 
the inflammation being uncontrollable by any means 
(even in the most skilful hands), the inflammation 
increase, and the pulse become harder; this is 
not the effect of the digitalis, any more than of 
venesection. Every practitioner of experience must 
have found the pulse become harder after a bleed- 
ing which has been insufficient to subdue the in- 
flammation, until another bleeding has softened it : 
the same occurs with digitalis. Doubtless digitalis, 
as well as venesection, may raise the pulse when it 
has been depressed below the natural standard by 
inflammation, as will be hereafter explained ; but 
will any one call venesection stimulant ? We should 
beware of attributing to the remedies the changes 




of pulse which depend on the progress of the 


A direct sedative diminishes the action of the 

heart and nervous system ; in a large dose, instead 
of hilarity, producing anxiety, depression, and des- 
pondency ; nay, more, allaying action in the ner- 
vous system, so that it cannot direct the muscles, 
the patient becoming giddy and staggering, and 
even the retina being so weakened as not to see 
distinctly ; so that a person may reel or see double 
without being intoxicated : the same may occur 
from loss of blood. It is well for the student to be 
early aware that opposite states may thus produce 
similar appearances, since the remedy which would 
cure one would not afford relief to the other : 
for instance, the coma of children which proceeds 
from inanition, and which might be mistaken for a 
plethoric state of the internal vessels, is relieved by 
stimulants, as is so well described by Gooch, and 
the nature of which was previously shewn by Dr. 
Marshal Hall. The disease called delirium tre- 
mens has likewise many symptoms in common with 
those complaints which are cured by venesection 
and sedatives, but which itself requires stimulants, 
either alone or combined with narcotics. 

We see that when nervous influence is ex- 
pended to the degree that ordinarily induces sleep, 
or the suspension of sensorial action, this suspen- 
sion is retarded if any irritation produce a renewal of 
sensations, as the pain of toothache, or if the extra- 
excitement of anxiety, in cases where affection or 
interest is concerned, continue to occasion extrica- 
tion of nervous influence in the brain : and this 


power of continuing cerebral action (wakefulness) 
will be increas ed by introducing into the stomach 
a sedative, such as digitalis, or green tea, which 
by diminishing the force of the pulse, and by its 
influence on the brain, counteracts the plethora 
which would induce sleep. But, observe, the 
natural powers are by this means forced; the 
consequence being, that from the expenditure 
of nervous influence continuing, with diminu- 
tion of the power of the heart and prima? via?, 
the brain will become weaker ; so that although 
thoughts may be excited, they will be vague, and 
false perceptions will arise. This state of morbid 
sensibility of the system is called being nervous, 
and is experienced by those who have sat up late 
watching the sick, or reading, and who, having for- 
cibly kept themselves awake, either with or with- 
out tea, coffee, or snuff,* become chilly, start at 
the slightest noise, and suffer involuntary and un- 
reasonable apprehensions of danger. Persons under 
these circumstances lying down in a cold bed, will 
frequently not fall asleep, or if they do, will be 
harassed by nightmare ;f but a warm bed, by di- 

* The effect of these luxuries, which are in reality often be- 
neficial, has been misunderstood : for instance, tea and coffee — 
sedatives — counteract the bad effects of wine and other fermented 
liquors ; as does also tobacco, whether in form of snuff or chewed. 
On the other hand, we observe persons render themselves debili- 
tated and nervous by too much tea and coffee without fermented 
liquors, especially females ; and in many instances, excess in snuff 
or tobacco injures the health by imperceptible degrees. 

f Nightmare is caused by whatever forces attention on the 
sensorium during sleep ; thus, it may be produced either by un- 
easiness in the stomach from indigestion, by cold of the surface, 
or by cold feet. 


minishing the sensations transmitted from the skin, 
and at the same time increasing the circulation, will 
renew a plethora in the brain favourable to sleep ; 
wine or spirits taken into the stomach will do the 
same, if the brain be not feverish ; or even a draught 
of hot water will have a beneficial effect. 

One example more of a direct sedative — a 
common dose of salts makes a person pale, and 
cooler in body and mind. This is not a simple se- 
dative, being likewise an evacuant ; at any rate, it 
is not a stimulant. I have heard emetics called sti- 
mulants ; but to this I cannot consent until I see 
a full dose of ipecacuanha or tartar emetic make 
a person feel warm and cheerful, and his pulse 
stronger, before or while he is sick. After the 
cessation of vomiting, by the relief of disease 
afforded by the emetic, the morbid sensibility, 
shivering, and depression, in ague, influenza, or in- 
flammation, are removed ; and from this cause, and 
not by a direct stimulant operation of the emetic, 
the patient may become warm, and be relieved from 
chilliness and anxiety of countenance, precisely as 
by venesection. 

Sedatives, as opposed to stimulants, diminish 
the injection of the brain, at the same time repress- 
ing the nervous influence : so that the proximate 
cause of delirium, stupor, or coma, from sedatives 
is inanition ; whereas the proximate cause of de- 
lirium and coma from stimulants is congestion or 

One cause of the confusion of terms is hereby 
explained. Sedatives are sometimes miscalled sti- 
mulants, when they relieve the vertigo, stupor, or 


coma of stimulants, or the drowsiness of fatigue 
or other plethora, because this relief is called 
arousing, or awakening ; as by tobacco-snuff, digi- 
talis, or tea.* On the contrary, a stimulant (wine) 
given to a person fatigued, produces an inclination 
to sleep, unless it occasion feverishness. 

Coffee appears occasionally to produce an effect 
the reverse of sedative : thus, in some persons it 
favours sleep ; a result attributable to the cir- 
cumstance, that sleep is often disturbed in con- 
sequence of a superabundance of blood in the 
brain, — being a feverish state, the effect of sti- 
mulant beverages, such as wine, &c. ; or the over- 
excitement of brain remaining after an evening 
passed in interesting society, at theatrical exhibi- 
tions, or in the arena of debate, when the ordinary 
status of the capillaries of the brain has been dis- 
turbed by exciting passions. 

In other cases, coffee and tea favour sleep by 
counteracting an habitually plethoric condition of 
the brain, depending on constitutional peculiarity 
and morbid activity of the heart's function, the 

* It is sometimes difficult to convince persons, who have been 
in the habit of resorting to tea or coffee for the purpose of en- 
abling them to apply the mind to any mental occupation, that 
these are sedatives, and diminish the action of the nervous sys- 
tem ; but they opearte only by counteracting the plethoric state 
of the brain induced by the continued stimulation of action, thus 
merely restoring the brain to its normal state. The same per- 
sons do not require tea on rising in the morning, when the brain 
is in its natural state, to enable them to study ; strong tea or 
coffee at that time would produce nausea or distraction of thought. 
On the other hand, some persons, whose brain is in a plethoric 
state, do require coffee or tea the first thing in the morning, to 
enable them to become quite awake. 


tendency of which to cause sleeplessness may be 
increased by the recumbent posture. 

The reader will perceive in the bulk of these 
observations an illustration of the oft-repeated re- 
mark, that opposite causes apparently produce in 
the animal economy the same effects. We have 
here pointed out that sleeplessness may arise from 
either excessive or insufficient injection of the 
brain ; that both fermented liquors (stimulants) and 
tea, coffee, digitalis (sedatives), may, according to 
circumstances, prove hypnotic or the reverse. 

By the term sedative is not to be understood 
that which puts to sleep, this being the operation 
of a narcotic, but whatever produces for a time an 
effect upon the nervous system as if it had been 
refreshed by sleep, by taking off plethora. But 
this, of course, has not the restorative effect of 
sleep ; on the contrary, though the ideas are ren- 
dered free at first, exhaustion will at length pro- 
duce the weakness of thought, the delirium ol- 
eoma of inanition ; as the sedative, besides its 
interference with the restorative influence of sleep, 
still further weakens the functions of the senso- 
rium, both by its local effect on the nervous tissue, 
and by its sedative effect on the heart, diminishing 
the supply of arterial blood to the brain. 

The narcotic principle in drugs diminishes the 
sensibility of the nervous system, lessens the per- 
ception of external objects, and checks volition, 
thereby allaying pain and promoting sleep. Narco- 
tics must be distinguished from stimulants on the one 
hand, and from sedatives on the other ; and the dis- 


tinction is the more necessary, because in nature 
the narcotic principle is generally combined with one 
or other of these, and sometimes also with an acrid 
irritating matter, which renders it difficult to draw 
correct inferences from experiments made with 
these substances : hence the contradictory and un- 
satisfactory reports of the value of different narco- 
tic remedies, and the difficulty experienced in their 
application by those who do not know the reason 
why opium suits one case, hyoscyamus another. 
It has been very common to try one of these reme- 
dies first, and if that did not suit, to resort to the 
other; but whoever knows that opium in its na- 
tural state contains stimulant and narcotic* proper- 
ties combined, will not administer it when the skin 
is hot and dry, with permanent thirst, delirium, and 
other evidences of symptomatic fever (pyrexia), 
but will on principle prefer hyoscyamus, which 
contains the sedative combined with the narcotic. 
Many have arrived at a knowledge of the con- 
trasted use of these substances empirically ; but 
those who have not experience must be guided by 
the consideration, that some " sleeping doses " are 
stimulant, and some sedative ; that a patient may 

* That opium contains two principles, the stimulant and nar- 
cotic, is not now matter of speculation ; as they have been 
separated chemically, and the narcotic part (morphia) can be used 
to produce sleep without the stimulant. The stupor from opium 
was said to be the sedative effect subsequent to, or produced by, 
the exhaustion of the stimulus ; but this is not the case, for the 
stimulant part being taken away, the morphia produces sleep 
just as certainly ; thus realising the long-sought desideratum of 
an unstimulating opiate — the vaunted nostrum, from the black 
drop, down to Battley's liquor. 


be forced by opium into a sleep from which he will 
awake thirsty, feverish, and unrefreshed, when hy- 
oscyamus would have cooled and refreshed him. 

Dover's powder is a judicious combination, 
when a narcotic neither sedative nor stimulant is 
required : the sulphate of potass and the ipecacu- 
anha being sedative counteract the stimulant part 
of opium, so that Dover's powder acts nearly as a 
simple narcotic. There are many cases in which 
hyoscyamus would be too depressing if given in 
doses sufficient to produce sleepiness, and in many 
cases opium would be too stimulating ; so that in 
fact, when we want narcotic without either stimu- 
lant or sedative, we cannot use the natural drugs 
uncombined. Hyoscyamus has been known to 
disappoint the practitioner, by inducing even de- 
lirium tremens instead of sleep ; which I attribute 
to this union of the sedative with the narcotic ; and 
which will also account for its being frequently 
found useful both in medical and surgical cases, 
when there is hot skin and hard pulse : this will 
explain the safety and advantage of using morphia, 
which is now so much employed empirically, from 
its possessing no stimulant properties. 

Battley's preparation, " liquor opii sedativus," 
is proved by experience to be analogous to Dover's 
powder, but suits many constitutions better; for the 
stimulant part of crude opium contained in Dover's 
powder disagrees more with some constitutions than 
with others ; and the advantage of the preparations 
of morphia may be similarly explained. Digitalis 
and opium may be advantageously combined ; but 
digitalis and brandy, a direct sedative and a direct 


stimulant, cannot be expected to produce any 
combined effect, the one neutralising the other ; 
as strong coffee or green tea tends to counteract 
the poisonous operation of tincture of opium, and 
the intoxicating effects of wine or other fermented 

Stimulants promote the extrication of nervous 
influence, as evinced by increased action ; seda- 
tives the reverse. Narcotics do not appear to alter 
the quantity of nervous influence, but merely to 
impede its communication : morphia, for instance, 
merely prevents the perception of pain in a part ; 
produces disinclination to muscular action ; does 
not alter primarily the force of the heart, like 
wine on the one hand, or digitalis on the other, 
but soon renders it sluggish by retarding innerva- 
tion. Narcotics stop the conducting power of 
the nerves, which may be thus illustrated: — if 
the arm be laid across the back of a chair, or be 
otherwise compressed in one place, the hand be- 
comes what is called asleep from pressure on the 
nerves ; sensation and voluntary action are lost, or, 
if not quite lost, much diminished, "pins and 
needles," a pricking sensation, being felt. The 
sensation of a limb being asleep arises from the 
pressure interrupting the conducting power of the 
nerves by pushing the medullary matter out of a 
part of them. If the medullary matter be but slightly 
separated, the nervous influence is passed like the 
sparks of electricity, causing the pricking ; but if 
the gap or space be too great, no sensation what- 
ever is transmitted. If the arm be rubbed so as 
to press back the medullary matter, the " pins and 


needles" are felt as it begins to meet. I have 
known the hand remain powerless for many months 
before the medullary matter could be rubbed into 
its place, in a person who, having fallen asleep 
with his head leaning on his fore-arm over the 
back of a chair, was affected with paralysis of the 
hand from this cause. This case is precisely ana- 
logous to the state of temporary numbness called 
being asleep, only lasting longer. The cause was 
clearly mechanical, and independent of any affec- 
'tion of the brain, as the muscles which bend the 
elbow, and all indeed above the point of pres- 
sure, were in perfect activity : there was no pain or 
other symptom of inflammation from which it could 
be suspected that inflammatory alteration of the 
nerves had suspended their functions. Narcotics, 
then, judging by the phenomena described, and 
others familiar to medical men, appear to inter- 
rupt the conducting power of the medullary mat- 
ter, evinced by their influence over the functions 
of the brain and spinal cord ; and as there is no 
mechanical pressure, we can account for this only 
by some chemical action or union with it, alter- 
ing its (galvanic or electrical) properties. 

Different narcotics vary as to their effects. A 
minute quantity, less than a grain, of extract of 
aconite (a sedative acro-narcotic), dissolved in the 
mouth and swallowed, produces a pricking sensa- 
tion, and diminution of power of the muscles of the 
fauces, so as to render speech and deglutition dif- 
ficult. Belladonna (a sedative narcotic) produces 
a similar effect, less a sense of pricking than of 


To recur again to the difference between nar- 
cotics and stimulants on the one hand, and nar- 
cotics and sedatives on the other ; sedatives dimi- 
nish action, but not by interrupting the conducting 
power ; for digitalis or green tea tend to render the 
perceptions more acute, and produce wakefulness 
instead of sleepiness : it is not until the nervous 
influence is actually exhausted, so as not to be 
sufficient in quantity to produce action, that there 
is any defect in the perceptions, and then there is 
delirium, not sleep. Aconite, belladonna, and to- 
bacco, which contain but little of the true narcotic 
principle in proportion to the sedative, are never 
used as hypnotic narcotics, as they produce deli- 
rium tremens ; whereas hyoscyamus, which con- 
tains a sufficient proportion of the narcotic, does 
not produce delirium tremens, except when mis- 
applied as concerns its sedative property ; and 
opium, which is narcotic and stimulant, never 
produces delirium tremens, though it may fail to 
procure sleep, if misapplied as respects its stimu- 
lant property. Thus, when administered in cases 
where feverishness exists, the small proportion of 
stimulus in the opium will often increase the fever- 
ish morbid sensibility, so as to counteract the nar- 
cotic influence. 

These three divisions of remedies may be con- 
sidered physiologically as well as pathologically ; 
that is, their action may be studied both on the 
healthy and diseased individual. We now come 
to the fourth division, tonics, which can only be 
considered pathologically, viz. with reference to 
their agency in removing a morbid state. 


Tonics are substances which neither imme- 
diately nor sensibly call forth actions, like stimu- 
lants, nor repress them, like sedatives, but give 
power to the nervous system to generate or secrete 
the nervous influence by which the whole frame is 
strengthened. The action of tonics (which can be 
traced to their effect on the nervous system) is 
gradual ; if therefore there be any sudden increase 
in force of the pulse immediately after their admi- 
nistration, it should not be attributed to their tonic 
nature, as the pulse will vary with the disease, 
according as it is affected by the use or neglect of 
other remedies. Thus, either the advance of inflam- 
mation, or the neglect of other remedies, or the 
administration of stimulants with tonics, will occa- 
sion that hardness of pulse which has usually 
hitherto been supposed to be the effect of a stimu- 
lant property in the tonic. On the contrary, a 
tonic, when it disagrees with the stomach, de- 
presses the pulse, acting as a sedative by nauseat- 
ing ; and even when it causes a quick pulse, which 
it sometimes does, with headache, this result is 
mere dyspeptic morbid sensibility. Even tartar 
emetic, which is recognised as the reverse of a 
stimulant, when its sedative operation is too great, 
or has been too long continued, induces the same 
state of morbid sensibility, which has been some- 
times denominated " antimonial fever." 

We have sufficient proof that the effect of qui- 
nine, iron, and arsenic, in neuralgia, &c., is direct 
on the nerves. There is a palpable analogy 
between the action of nitrate of silver, sulphate of 
copper, arsenic, &c, on sores, and their effect on 


the constitution when introduced through the cir- 
culating fluids. In either case, if used in too great 
quantity, they will do harm ; externally, instead 
of constringing and healing, they prove caustic ; 
internally, also, too much is poisonous : but bark 
or carbonate of iron, which do not produce che- 
mical decomposition, are free from the risk of 
acting as caustic or poison. Some tonics, then, 
in excess, as well as stimulants and sedatives, be- 
come poisonous. Arsenic produces inflammation, 
as a poison ; but this is not to be referred to when 
considering the tonic effect of small doses of the 
mineral ; the tonic effect being a modification of 
vital actions, the caustic or poisonous effect a de- 
struction of the machinery. There is no analogy 
between the effect of the tonic in proper doses, 
and the diseased state produced by it when it acts 
as a caustic poison. Lunar caustic properly applied 
will heal the skin ; improperly, will burn a hole in 
it. Whoever does not know of what strength to 
use nitrate of silver, or sulphate of copper, had 
better confine himself to oak-bark or alum, which 
cannot corrode ; or if he does not know how to 
modify arsenic or croton oil, he had better trust 
exclusively to Peruvian bark and castor oil, though 
less efficacious in many difficult cases. Thus, if 
a man be dexterous, he can perform lithotomy 
best with Mr. T. Blizard's knife ; but if not, he had 
better use a gorget : as an awkward ploughman 
will go safer with a plough that is guaged by a 
wheel, than with one that is entirely dependent on 
the management of skilful hands, but which, when 


well guided, is the safest and most efficacious, espe- 
cially in difficult circumstances and rocky ground. 

Therapeutics and toxicology require very dif- 
ferent modes of investigation ; and notwithstand- 
ing that experiments which have been made with 
poisons are very interesting and useful for the pur- 
pose of finding antidotes, they do not advance us 
much in reasoning upon the remedial use of these 

In some cases, by temporarily exciting the ner- 
vous system when weak, stimulants give the diges- 
tive organs more power for the moment : the new 
nourishment increases the strength of nerve as well 
as of other parts ; and thus stimulants and gene- 
rous diet become in reality a part of the tonic plan ; 
and from stimulants being so often administered 
with tonics, tonics have been thought stimulant. 
It is of the utmost consequence to know that they 
are not so, otherwise there may be a fear of using 
them where they would be very beneficial, com- 
bined with evacuants and sedatives ; for quinine 
or other tonics may be advantageously used along 
with digitalis and bleeding on the one hand, or 
with wine on the other. For instance, it is well 
known that ague attacks the most opposite consti- 
tutions, and that some patients stand in need of 
support, while others, on the contrary, require se- 
datives, such as venesection, opening medicines, 
and emetics — still, with the tonics, bark or arsenic, 
in both cases — to cure it. 

Medical men were formerly so strongly imbued 
with the idea of bark being stimulant, that they pre- 


pared the patient, as they called it, by using the 
antiphlogistic treatment before they ventured to 
begin the tonic ; but practical experience has long 
since disproved the necessity of this precaution, and 
few now spend time in unnecessary preparation by 
other medicine, or bleed, except when the state of 
the pulse, and other symptoms, indicate its pro- 
priety. Tonics, then, being intrinsically neither 
stimulant nor sedative, may be usefully combined 
with either; for whether we want to keep down 
the pulse in inflammation, or to raise it and the 
appetite, &c. in debility, it must obviously be de- 
sirable to give tone and strength to the ner- 
vous system at the same time ; because tone 
and strength of the nervous system will not in- 
crease the action of the heart unless it be called 
forth by stimulants. We must observe this differ- 
ence : tonics give strength, stimulants call it forth ; 
a man may be very strong without putting forth 
his strength. We need not fear any danger from 
keeping the nervous system in good order by 
tonics, but we must beware of exciting over- 
action by stimulants, when either inflammation or 
fever exists. Stimulants excite action, but action 
is not strength ; on the contrary, we shall see, 
when we come to consider fever, that over-action 
increases exhaustion. 

A correct understanding of these distinctions 
will be found of great use. The constitution 
may sink under the depletion necessary to re- 
duce inflammation, or subsequently during tedious 
reparatory process, if tone cannot be kept up ; but 
this may be done without stimulation. Often is 


the practitioner foiled by " pouring in the bark 
and wine :" seeing the inflammation relighted, he 
is obliged to leave off the stimulant ; but as he in- 
cludes the tonic under that head, he leaves that 
off too, and so loses ground : or else, knowing by 
experience that if he leave off the tonic, the patient 
will certainly sink, he continues the two together 
at all hazards, till perhaps the inflammation and 
stimulus united destroy by fever. 

It must not be imagined, however, as is too 
often the case with students, whenever a patient 
dies, that he might have been saved : they will be 
convinced by morbid anatomy and experience, that 
many cases of disease are uncontrollable by human 
skill and means ; but, at the same time, the seeing 
how much had been effected in ultimately fatal 
cases, will encourage them in steadily practising on 
rational principles, and prevent their wavering in 
cases which are curable, though tedious. 

Tonics, such as bark, then, by imparting healthy 
energy to the capillary arteries, have a beneficial 
effect on inflammation (the erysipelatous and rheu- 
matic, for instance), even when bleeding and seda- 
tives may be necessary to keep down the action of 
the heart ; but so long as the action of the heart is 
not below par, the effect of stimulants would be in- 
jurious. Sometimes, even when the acute stage of 
inflammation has subsided or been subdued, the 
powers of the constitution are so much reduced, 
that the reparatory process degenerates, so that 
parts cannot heal ; hence the advantage of giving 
tonics to prevent this state as much as possible 
(even whilst we are keeping down the pulse by 


bleeding, sedatives, and cathartics), if the constitu- 
tion seem to require it ; but by no means should 
we administer stimulants in the acute stage. As 
soon, however, as the acute stage or the inflam- 
mation is passed, and the reparatory process, or 
passive stage of resolution, commences, we must 
watch for the moment when it may be necessary 
to administer stimulants to prevent degeneration of 
the process, the local symptoms of which are livi- 
dity, diminution of temperature, &c. ; the general 
symptoms, feeble pulse and anorexia. If tonics be 
not given early, as they act but slowly, there may 
not be time to introduce them into the system when 
the acute stage has been subdued ; and there may 
not be sufficient strength for stimulants and food to 
work upon towards restoration. 

It is evident that tonics must be considered 
distinctly from stimulants and sedatives, from the 
circumstance that we cannot cure an ague or neur- 
algia, either by stimulants or antiphlogistic treat- 
ment, without tonics. We know that many slight 
cases of either will get well if left to nature ; but 
I allude to those which are severe or obstinate. 

The term tonic is applicable to all those medi- 
cines which cure chronic inflammation without being 
either stimulant, or directly sedative or depletory. 
There are various cases in which bleeding, cathar- 
tics, emetics, and other sedative or antiphlogistic 
remedies, have not power to stop inflammation, 
and yet, together with the disease, are wearing 
down the constitution : under these circumstances, 
recourse has been commonly had to mercury. 
There are also cases in which arsenic, bark, 



opium, or other medicines, are preferable; but 
the great nostrum has been mercury: and yet, 
though so useful in the most ignorant hands, 
it is difficult to account for or designate its ac- 
tion. It is often called a stimulant, and yet it 
cures inflammation when all stimulants are care- 
fully withheld, and so coincides in its action with 
the sedatives, and might as justly be called a seda- 
tive. But it also cures inflammation in debilitated 
habits, when wine and other stimulants are neces- 
sarily administered. I therefore consider mercury 
neither stimulant nor sedative, but tonic ; that is, by 
its specific action on the capillaries, whether directly 
on their tissue, or through the medium of their 
nerves, it causes them to contract, when (though 
all the injecting force of the heart were taken off by 
sedative treatment) they would not have had power 
to close ; for when introduced into the system, it 
circulates to the capillaries, and gives them tone to 
contract, analogous to the effect of an astringent 
applied to external sores. Liquor arsenicalis, ni- 
trate of silver, the sulphates of copper and iron, 
mezereon, dulcamara, colchicum, &c, have a simi- 
lar action ; some of which are more available than 
others in particular cases. 

This is also the rationale of the operation of 
the so-called alteratives, and of what is called sti- 
mulating the secretions of internal organs. When 
their capillaries are weak, they have their tone 
restored by mercury, and the secretions are thus 
renewed ; but it should not be forgotten that mer- 
cury, like some other tonics, in excess becomes 
poisonous, and may cause inflammation in other 


parts, as it does in the gums, on the principle 
adduced before, that one degree of contraction of 
the capillaries is necessary to reduce inflammation, 
while a still further degree will stop nutrition, and 
bring on wasting and disease ; as syphilis has been 
by some starved out at the expense of the con- 
stitution. Iodine, arsenic, and sulphate of copper, 
occasionally produce ptyalism, and are otherwise 
analogous to mercury in their action. Rheumatic 
inflammation in the fibrous and other tissues, the 
capillaries of which are very minute, often cannot be 
cured by common depletory antiphlogistic means, as 
above mentioned ; but yield to colchicum, mercury, 
antimony, bark, &c, introduced into the capillaries 
through the circulation. 

The tonic property is frequently combined with 
astringency ; but that they are not identical is evi- 
dent from quinine, which contains no tannin, and 
cinchona bark, which contains very little, being 
highly tonic ; while tannin, oak-bark, and catechu, 
are very slightly so. Still, however, we are at a 
loss to conceive any other than an astringent effect 
produced primarily by the tonic substances. All 
the metallic salts have, more or less, an astringent 
effect on the capillaries ; and to this influence I 
attribute the universal efficacy of antimony as an 
antiphlogistic remedy, it being doubly valuable in 
acute cases, from its sedative effects on the heart 
and pulse, combined with its locally tonic or as- 
tringent effects on the capillaries of inflamed or 
congested parts, as well as on those of all the 
secreting structures. Hence, too, its efficacy, in 
small repeated doses, in cases where there is great 


depression of the system, by its relieving the relax- 
ation of the capillaries by which the depression is 
caused. Nay, more, we can manage to insure its 
full antiphlogistic effects without the inconvenience 
of nausea, by combining it with a little opiate and 

From the analogy of the efficacy of tonic 
medicine in curing chronic inflammations and 
neuralgic diseases, we may, I think, infer, that the 
latter depend on a chronic inflammatory state of 
the nervous tissue ; though, from its capillaries 
being so fine, it is at present impossible to detect 
that state. 

As I set out with observing, it may be seen 
that tonics must always be considered in reference 
to disease : thus, different substances which, con- 
sidered physiologically, or in health, belong to 
opposite classes, become, in disease, tonics. Even 
narcotics frequently become, in an indirect manner, 
most usefully tonic ; as, for instance, when rest is 
prevented by the morbid sensibility of a sore which 
will not heal, banishing " kind nature's sweet re- 
storer, balmy sleep ;" stimulants in this case cannot 
procure repose nor give strength; sedatives are not 
required, or rather are contra-indicated ; sometimes 
even one dose of a narcotic, by procuring a good 
night's rest, will renew the restorative energy of the 
system ; although a single dose will not, in general, 
suffice. The value of repeated small doses of opium 
m chronic periosteal diseases, and what are called 
irritable sores, as exemplified in Pott's treatment of 
gangraena senilis, is well known to surgeons; and 
also to physicians in chronic affections of the mil- 



cous membranes, &c Its applicability to irritable 
sores shews that the efficacy lies in the narcotic 
quality, though it is commonly attributed to a sti- 
mulant one even by those surgeons who know how 
much more they can effect, in such cases, by ad- 
ministering from a quarter of a grain to a grain of 
opium twice or three times in the twenty-four hours, 
than by giving wine, spirits, or beer, which are in- 
comparably more stimulant. On the other hand, 
when the constitutional state is that of debility, 
rather than irritability (morbid sensibility), as in 
strumous and certain other cases, fermented liquors 
are of much more value than opium. There is no- 
thing more efficacious than opium in catarrh ; but, 
from the idea of its being stimulating, or heating, 
which it appeared to be chiefly where it confined 
the bowels, we find that all the experienced prac- 
titioners formerly combined it with small quantities 
of jalap, ipecacuanha, &c. in catarrhal affections. 

I take this opportunity of pointing out the com- 
mon error with respect to opium. It will be much 
better to get a clear notion of the nature of reme- 
dies, and to call them by their right names; as, for 
instance, not to denominate opium either stimulant, 
sedative, or tonic, but to understand its use by its 
true name of narcotic. Its beneficial effect arises 
from its narcotic property diminishing that morbid 
sensibility which prevents sleep, digestion, and other 
restorative processes : and this is the principle 
to be followed in the administration of narcotics. 
The choice of them has already been explained, as 
to opium, hyoscyamus, morphia, tincture of opium, 
Dover's powder, &c. Sir Astley Cooper recom- 

1 \ 



mends opium to be given when mercury is em- 
ployed, which is a judicious precaution, as the latter 
has a tendency, though primarily a tonic, to pro- 
duce morbid sensibility secondarily. These few 
words will serve as a clue to the use and abuse of 
mercury. Mr. Skey, in a useful little practical 
work on the treatment of ulcers, has brought 
forward evidence which supports my opinion of 
the explanation of the utility of opium ; though 
he seems to think the benefit is owing to a 
stimulant effect of the opium upon the capil- 
laries. Opium is invaluable to the accoucheur, 
to allay the morbid sensibility which occurs after 
parturition. Some use it in the puerperal state 
as a " cordial," some as a " sedative," some to 
" bring on " action, some to " allay " it ; as, for 
instance, to assist labour when it flags; or, on 
the contrary, to check inordinate uterine contrac- 
tions. If the midwifery practitioner will recollect 
that the object is to allay morbid sensibility, he 
will be certain in its application ; whether he be 
obliged to use the narcotic with stimulants on 
the one hand, or with depletion and sedatives on 
the other. 

This distinction of stimulants, sedatives, narcotics, 
and tonics, assists in understanding the operation 
of remedies in various diseases, it being recollected 
that the medicines which are used as purgatives 
and emetics, such as salts, senna, jalap, tartar eme- 
tic, calomel, ipecacuanha, &c, are sedative in their 
operation. The effect of tartar emetic is some- 
times intended to be merely local, for the purpose 
of emptying the stomach, and then it is given in a 


full dose ; but it will perhaps surprise some to learn 
that tartar emetic, as a general sedative remedy, 
will allay sickness. For example, inflammation of 
the mucous membrane of the intestines is accom- 
panied by nausea and sickness :• these symptoms 
may be checked sometimes, even without bleed- 
ing, by frequently repeated small doses of tartar 
emetic, called by some febrifuge. 

We see that the action of medicinal agents 
becomes most opposite when the proportional 
quantities are varied, and according to the state of 
disease which may exist; hence it requires great 
attention to separate the causes of phenomena, 
and duly estimate them. The whole practice of 
the healing art is full of apparent contradictions : 
for instance, opium makes the pulse hard or soft, 
promotes and takes away appetite ; the same means 
appear in one instance stimulant, in another seda- 
tive ; venesection sometimes makes the pulse smaller, 
sometimes fuller. But when we speak of remedies 
as stimulant, sedative, narcotic, tonic, and their com- 
pounds, we are to consider their moderate action 
whilst they are working on the natural powers of 
the organs, and not their exaggerated or poisonous 
effects when they begin to excite either inflamma- 
tion or morbid sensibility ; or, again, when they 

* A patient was admitted into the London Hospital, who 
had been labouring under diarrhoea and vomiting for two days, 
for which he had taken chalk-mixture, catechu, opiates, &c, 
unavailingly. His skin was hot and dry, with wiry pulse, dry 
tongue, &c. I prescribed one sixteenth of a grain of antim. tart, 
every two hours. He did not vomit after the second dose, and 
rapidly recovered. 



suspend the vital functions, as sedatives do in ex- 
cess, in which case they have frequently been mis- 
named narcotics, as has been done with colchicum, 
digitalis, hydrocyanic acid, &c. ; which, though 
in excess they may produce vertigo or insensibi- 
lity, do not terminate in sleep, but in fainting or 
death. Brandy or wine, in moderation, acts as a 
stimulant upon the nerves of the stomach and 
other parts in a healthy state ; in too great quan- 
tity, there is a noxious effect on the organ, its 
natural susceptibilities being perverted, and a 
sedative effect communicated to the nerves of 
the heart, &c, so that a person intoxicated will 
become sick, with cold sweat and a weak pulse, 
though wine and brandy are stimulants. Again, 
the state of disease causes deception as to the 
nature of an agent : for in inflammation, which 
makes the pulse weak from its severity, brandy, 
by increasing the inflammation, would weaken it 
still more ; whilst sometimes, on the other hand, 
sedatives, as digitalis, antimony, and bleeding, as 
has already been explained, raise the pulse by re- 
lieving the inflammation. 

Tonics, even mild ones, as bark and iron, will 
excite nausea, when there is much of that morbid 
sensibility of stomach, which they will eventually 
cure, if gradually introduced ; others, in excess, 
as arsenic, will occasion morbid sensibility and in- 
flammation of the gastric and intestinal mucous 
membrane, which appears to confirm the opinions 
of Broussais. Nevertheless, the full tonic or seda- 
tive effects of medicines may be produced without 
risk, and with benefit, if administered in proper 


quantities, and not misused ; though this patho- 
logist anathematise arsenic, salts, senna, tartar 
emetic, &c. Praised be Rasori and his followers, 
Tommasini and the rest, who have given us my- 
riads of proofs of this, if our British practice did 
not afford a sufficiency. Sulphuric, nitric, and 
oxalic acids, in their concentrated state, like 
arsenic, produce fatal inflammation ; yet when 
sufficiently diluted with water, not only afford an 
agreeable and refreshing beverage, but are efficient 
in allaying inflammation. 

The varieties of inflammation may be under- 
stood by always recollecting that the heart is act- 
ing against the arteries, and that both heart and 
arteries derive their power from the nerves. Thus, 
inflammation may go on when the pulse is very 
weak, and when the heart is acting much more 
feebly than natural; but the arteries being even 
weaker in proportion, give way, as we see in broken- 
down constitutions, where inflammation is cured 
by stimulants, which raise the pulse, but which, at 
the same time, by improving the appetite and diges- 
tion, nourish and increase the energy of the ner- 
vous system, so as to communicate to the capillaries 
a tone or power to resume their healthy action, 
more than equivalent to the increased action of 
the heart. In some cases, by good food, and tonics 
such as bark, without stimulants, we communicate 
an energy to the nervous system, which restores 
the healthy action of the capillary arteries ; and 
it is the discrimination of cases where stimulants 
are admissible with tonics, or where tonics should 


be accompanied by evacuants, that constitutes 
skill in conducting the constitutional treatment of 
many diseases. Thus, by a reference to the relative 
state of action of the heart and arteries, bearing in 
mind their dependence upon the nervous system, 
we can understand how tonics are useful in many 
instances, by communicating power to the capil- 
lary arteries through the nerves, where stimulants 
would be injurious, from their increasing the heart's 
action. Tonics are likewise beneficial, in con- 
junction with abstraction of blood and evacuant 
remedies, in keeping up the energy of the nervous 
system, so as to restore the proper action of the 

To beginners, the treatment of inflammation in 
different ways must appear contradictory ; even 
to practitioners of experience, it is sometimes dif- 
ficult ; but it will be found rational and consistent 
by those who have a clear conception of the modus 
operandi of medicines, and by a reference to the 
various states, both of the parts and of the con- 
stitution, which exist under the name of inflam- 

Let us now examine some of the more common 
phenomena of inflammatory affections, and the 
remedies applicable, in order to see how far we are 
borne out in the preceding statements, beginning 
with the simplest forms, unconnected with what is 
called constitutional disturbance, and proceeding to 
the more aggravated and serious forms of disease. 
As an instance, let us take the eye, or some part of 
the skin, subjected to a blow, or a stream of cold 
air ; or heat applied to the skin, so as to give pain 


and excite redness, without blistering ; or the effect 
of a mustard poultice, or of a cantharides plaister 
taken off before it has had time to raise a blister, hav- 
ing only produced redness : here, upon visible parts, 
the first and slightest degree of inflammation arises, 
that is, a blush of redness, with a degree of tumefac- 
tion of the vessels, and pain, or a sensation of heat 
or itching in the parts. Or let us suppose a mucous 
membrane slightly injured, as that of the nose or 
windpipe, by sudden alternation of temperature, &c., 
producing either painful dryness, or an increased 
flow of mucus, with uneasiness or itching, which is 
the slightest degree of inflammation in those parts, 
commonly called catarrh ; or the mucous mem- 
brane of the intestines injured by bad food, as sour 
fruit or sour wine, which produces a flow of mucous 
or watery fluid, with uneasiness or griping, called 

I must here explain the apparently contradic- 
tory assertion, that the distended state of the 
capillaries at one time produces an increased flow 
of mucus, and at another causes dryness. In their 
healthy state, the mucous membranes are scarcely 
moistened by their vessels, any more than the 
serous — they are merely kept lubricated and soft; 
but the effect produced by the first degree of 
inflammation of the mucous surfaces is, by the 
relaxation of the exhalent capillaries, a more rapid 
extrication of the fluid part of the blood, a thin- 
ner saline serous (coryzal) fluid, instead of bland 
mucus ; but as inflammation subsides, the vessels, 
recontracting, secrete a mild scanty mucus again : 
these are the well-known phenomena of that slight 


degree of inflammation, catarrh, which occurs in 
cold weather, and lasts often only a few hours. 
The effect produced by a higher degree of inflam- 
mation of the mucous surface, is dryness — a stop- 
page of secretion (as explained p. 33 et seq.), which 
state Laennec denominates " dry stage of catarrh " 
(dry flux !), but for which the old term bronchitis 
is the correct one. It seems that he could not 
reconcile the use of the word bronchitis with the 
stimulant treatment useful in many cases of catarrh, 
and which he extends even to some cases of bron- 
chitis ; for though he has mentioned the use of 
stimulants empirically, he has by no means ex- 
plained it, nor given any satisfactory rules to guide 
in the selection of stimulants or sedatives in the 
" dry stage of catarrh," which has even led some 
to doubt whether catarrh be inflammation. It 
should be understood that the dry stage is bron- 
chitis ; and while it lasts, stimulants should be 
withheld, inasmuch as, at a stage higher than that, 
mischief and disorganisation would commence ; 
but when there is merely catarrh, congestion and 
relaxation of the capillaries, the stimulants, by 
increasing nervous energy, on the principle laid 
down, do more good to the capillaries than any 
increase of the heart's action could harm them. 
Thus stimulants with opium usually cure catarrh, 
and frequently augment bronchitis. 

We cannot have a better opportunity than this 
of explaining the rule for diet ; and it will be seen 
that some old popular sayings, resulting from expe- 
rience, are based on truth — e. g. " feed a cold, and 
starve a fever." It will be found, generally speak- 


ing, that it is not necessary to starve a fever ; one 
of the first evidences of fever, however slight, being 
want of appetite (anorexia). Natural instincts are 
too often thwarted ; it is much too common to 
put patients empirically on low diet ; and pa- 
tients of the higher classes, the better educated, 
very often put themselves on low diet unneces- 
sarily. How frequently have I been consulted by 
persons for aggravated catarrh, which they said 
was " getting worse and worse, though they had 
been living low, taking slops, and no wine," and, 
perhaps, opening medicine. The nerves and ca- 
pillaries, which would have recovered their tone 
under the ordinary diet, were thus kept debilitated 
by the unnecessary sedative treatment. 

The cases just described are curable in a few 
hours by animal food, a glass of wine or other fer- 
mented liquor, and a dose or two of any opiate, 
unless, perhaps, the outraged stomach have lost its 
appetite, in which case a few days' tonic treatment 
will be required to undo the mischief. Thus, so 
far as we may take natural instinct for a guide, we 
may assert, that when a patient can eat, he may be 
allowed to do so ; for if he have even a slight de- 
gree of fever, he caimot eat. This will also direct 
us in the use of wine, &c. ; the loss of appetite, 
shewing feverishness, requires the withholding of 
stimulants ; except that sometimes, in chronic cases 
and convalescence, delicate persons require a little 
stimulus to the stomach to induce them to begin 
to take food. Again ; so long as the appetite con- 
tinues good, fermented liquors may be used ; but 



as no rule is without exceptions, so there are of 
course many both medical and surgical cases of in- 
flammation, in which, though the appetite have 
not failed, it is necessary to forbid stimulants. 

These instances of simple local disease hitherto 
adduced depend upon one morbid change, viz. an 
enlarged state of the minute capillaries of the part, 
from their tone being diminished, either from the 
vessels themselves being injured, as by a blow, or 
by their nerves suffering injury from excess of cold 
or heat, or acrid matter applied to them. 

In the examples given, the parts generally re- 
cover of themselves gradually, the vessels contract- 
ing to their natural size ; or, if they do not, mere 
local means will be sufficient to restore them to a 
healthy state, such as the application of cold and 
astringent lotions, with abstraction of blood by 
leeches, to unload the vessels ; warm stimulating 
liquids or astringents internally, warm fomentations 
externally, acting through the medium of the 
nerves ; and thus either the inflammation is cured, 
or it subsides without remedies, by what is called 

In considering these examples of simple local 
inflammation, I have made no mention of constitu- 
tional symptoms. The nervous system, the brain, 
spinal cord, and ganglionic nerves, are not sympa- 
thetically affected ; the heart's action, as measured 
by the pulse, is unaltered ; the digestive system is 
unimpaired ; the appetite, and the functions of the 
intestines and kidneys, go on as before. 


As a second state of disease, let us investi- 
gate a greater degree of local injury, where the 
minute arteries have suffered so much that they 
cannot recover of themselves, nor by the aid of 
mere local applications. Here the first symp- 
toms of constitutional disturbance arise, viz. rest- 
lessness, or a general sense of uneasiness, and in- 
creased action of the heart ; shewing that the ner- 
vous system is partaking of the morbid sensibility 
of the nerves of the inflamed part, and that the ir- 
ritability of the heart is increased, rendering it more 
excitable by its ordinary stimulus, the nervous 
centre from whence its nerves are derived, being 
more susceptible. A very common effect of the 
derangement of the nervous system in this stage is 
a diminution of sleep, which is sometimes attributed 
to pain, but which really depends more on the 
degree to which the nervous system is affected ; 
for persons will sleep at one time with much more 
severe pain than that which will at another banish 
rest. In the present instance, however, in addition 
to the local disease, which exists as in the first case, 
the most marked symptom is increased force in the 
pulse ; and as this increase of force in the injecting 
action of the heart tends to keep up and aggravate 
the disease, it is necessary to diminish its action 
and guard against renewal. To diminish the vis a 
tergo, we may either take blood by venesection ; 
or, by putting on a greater number of leeches than 
in the former case, we may lower the pulse at the 
same time that we relieve local fulness : having thus 
lowered the pulse, we are to avoid every thing that 
might raise it again ; and as exercise and generous 


diet do this, rest and low diet are essential parts of 
the anti-inflammatory, or antiphlogistic treatment. 
In addition to rest and low diet, we possess other 
means of lowering the pulse besides abstraction of 
blood; that is to say, by sedatives, and by drugs 
of the emetic and purgative kind, both of which, 
by diminishing the action of the nervous system, 
in addition to their ordinary evacuant effect, have 
a tendency to produce temporary faintness and 
weak pulse. Their sedative effect on the nervous 
system constitutes their utility in inflammatory dis- 
ease, usually more than the mere emptying of the 
stomach and bowels : and for this reason we admi- 
nister antimonials, neutral salts, &c, in frequent 
small doses, which do not cause vomiting or purg- 
ing, under circumstances where we wish neither to 
take away blood, nor to exhibit cathartics or eme- 
tics in full evacuant doses. Digitalis has a power 
of controlling the action of the heart ; but though 
it has its advantages, its influence is not so cer- 
tain and manageable as to make it a substitute 
for blood-letting, the relief from which is usually 
instantaneous ; whereas some hours at least are 
necessary for digitalis to produce its effect ; and 
when it begins to lower the pulse, if rapidly intro- 
duced into the system, it must then be closely 
watched, lest it produce too great depression : so 
that, in acute diseases, digitalis may assist, but 
cannot generally supersede blood-letting ; while, on 
the other hand, it is of the greatest use when blood 
cannot be spared. 

The statement hitherto made will account for 
the great benefit of opium after inflammation ; 


when often morbid sensibility remains, which would 
wear out and destroy the patient, though the in- 
flammation be past, or stopped by bleeding, or 
other remedies. Opium, which is usually considered 
inadmissible during inflammation, until depletion 
has been employed, is of great advantage, when 
it is subsiding or past, in supporting the system 
under a great injury during the restorative process. 
The use of opium has been pointed out by the best 
authorities, in peritonitis, peripneumonia, &c, or 
whilst the inflammation is decreasing, and during 
the reparation of the injured parts. In the cases 
alluded to, it is given immediately after free bleed- 
ing : the bleeding checks the inflammation, and the 
opium removes the morbid sensibility. On any 
relapse of the inflammation, evinced by the skin be- 
coming hot and dry, the opium must be combined 
with renewed antiphlogistic remedies. The case 
must be closely watched for febrile symptoms, 
lest the anodyne, by allaying pain, deceive the 
practitioner (of which there is great danger in in- 
experienced hands), and the inflammation re-light, 
as it will, unless antiphlogistic medicines, such as 
antimony, digitalis, neutral salts, &c, be adminis- 
tered to keep it in check, in graduated doses, but 
by no means freely, though that was necessary 
at first. 

Opium has frequently been used empirically 
with antiphlogistic remedies to relieve pain ; but it 
is, in many instances, itself antiphlogistic : for by 
allaying morbid sensibility, it prevents the inordinate 
action of the heart (p. Ill), characteristic of inflam- 
mation, and thus keeps the pulse from becoming hard. 


Nay, more ; morphia, in particular cases, proves 
most powerfully antiphlogistic — even sedative,* 
secondarily ; for by its suspending the appetite 
and digestion, and depressing the action of the 
heart by diminishing innervation, the patient is 
soon debilitated. In fact, morphia in large doses, 
combined with mercury, antimony, colchicum, &c, 
at the onset of inflammation, as in acute rheuma- 
tism or visceral inflammation, sometimes super- 
sedes the lancet, particularly in constitutions in 
which, after loss of blood, a tedious convalescence 
might be expected. The debility produced by mor- 
phia, mercury, antimony, &c, when not the result 
of any evacuant effect of these remedies, is indirect 
and easily recovered from. Patients sometimes 
become- so weak from the influence of repeated 
doses of morphia, as to require wine. 

We may, I think, account for the diversity of 
reports made as to the ill effects of " opium-eating" 
on the constitution, by considering the various cir- 
cumstances as to diet, exercise, &c, under which 
this vice is indulged in. The indolent Asiatics, 
who take their dose and sit still, indulging their 
reveries, neglect taking food, or the appetite and 
digestion become impaired, so that the frame is 
destroyed, as has been usually described ; but in 
this country this is not always the case, except 
with the rich, and, above all, the indolent. Many 
of the lower classes, with whom the practice may 

* This is the effect of even crude opium with some constitu- 
tions ; hence it has been freely used by many practitioners ; whilst 
others, having found certain of its constituents irritate patients more 
in proportion than the morphia calmed them, have avoided its use. 


be considered almost as a virtuous substitute for the 
common vice of gin -drinking, are not permitted 
by the necessity of daily labour to neglect exercise; 
and thus retaining their appetite for food, suffer 
little or nothing from the opium. In the higher 
classes, unless indolence combine, the opium does 
not prove always destructive of the constitution. 

Notwithstanding what was formerly said of 
sedatives diminishing the drowsiness of plethora, it 
is nevertheless true that digitalis will procure sleep 
where excitement and wakefulness have been kept 
up by inflammation of the brain, congestion of 
the lungs, &c, with a full hard pulse, such as 
we often feel with hypertrophy of the heart, and 
which hardness must be combated by digitalis, after 
bleeding, &c. (see page 85). The diseases of the 
heart being organic (structural), no amount of 
bleeding could remove them ; but they may be re- 
lieved by digitalis, hydrocyanic acid, &c, without 
profuse expenditure of blood. 

It is needless, however, for me to multiply ex- 
amples : the student must apply the rules at the 
bed-side ; and the memory of any man of expe- 
rience who reads this will supply him with illus- 
trations : but this organic cause of hard pulse is 
worth mentioning, as it is a source of embarrass- 
ment to young practitioners. 

This affords another instance of remedies be 
longing to a certain class acting, under peculiar 
circumstances, after the manner of those of a dif- 
ferent class ; for although venesection or digitalis 
may procure sleep by their sedative influence in 
lowering the force of the circulation, as described, 


neither of them are narcotics. Yet digitalis or ve- 
nesection do not always act by lowering the activity 
of the circulation, or injecting power: on the con- 
trary, we have before alluded to their raising the 
pulse (p. 104), in opposition to their properties as 
sedatives. This fact shews the necessity of refer- 
ring to the proximate cause of inflammation — the 
state of the capillaries ; for in the cases alluded to, 
the cure of the inflammation is effected by the 
operation of the remedies on the capillaries, not by 
their effect on the circulation ; the venesection re- 
lieving the capillaries mechanically by diminishing 
the quantity of blood, — the sedative by its constrin- 
gent property increasing the contractile action of 
the vessels. 

Hydrocyanic acid is a valuable sedative in 
such cases as whooping-cough, phrenitis, &c. It 
may be used as a sedative when digitalis disagrees 
with the stomach or head ; thus we may sometimes 
relieve the excessive action in hypertrophy of the 
heart by hydrocyanic acid, and at the same time 
improve the digestion by it, after having been 
obliged to forego the digitalis, on account of its 
producing nausea and cardialgia, although it had 
reduced the pulsation. Hydrocyanic acid is a use- 
ful remedy for that dyspepsia which is caused by 
hyperemia of the primae viae : and it may here be 
observed, that if more attention were paid to dis- 
cover the proximate cause of the individual cases 
of dyspepsia, the disease would not be found so 
difficult to cure, The depressing effect of digitalis 
on the spirits and appetite is frequently a serious 
objection to its use, notwithstanding its great value 


as a sedative remedy. Besides hydrocyanic acid, 
morphia, a narcotic which is secondarily sedative, 
may sometimes be substituted for digitalis ; never- 
theless, there are many cases in which the expe- 
rienced practitioner will use digitalis with much 
more effect than either of those remedies. 

In the first and second cases, or degrees of 
inflammation hitherto considered, we have had the 
same structures under consideration, as the sub- 
jects of local disease produced by injury of some 
kind, viz. the eye, the skin, the mucous membranes 
of the chest, or abdomen ; as subjects of slight 
ophthalmia, erysipelas, bronchitis, catarrh, and di- 
arrhoea ; but curable before having gone the length 
of producing what is called constitutional disturb- 
ance, except raising the pulse ; and but few reme- 
dial agents have been mentioned, nothing having 
been said of blisters and other counter-irritants, or 
the warm bath, &c, but merely what is judged suf- 
ficient for a brief illustration of the subject. 

The raising of the pulse we have traced to 
morbid sensibility propagated from an inflamed 
part. Before proceeding farther, it is necessary to 
consider more particularly this morbid state of the 
nerves, whether partial or general, to which the 
word " irritation " has been usually applied, but for 
which I have adopted the term morbid sensibility. 
By morbid sensibility is meant that state of the 
nerves or central organs which renders them more 
susceptible to impressions than natural. And in 
order to explain the occurrence of morbid sensi- 
bility in its various forms in different organs, we 


must assume that the nerves of proper sensation, 
the organic, and the incident filaments, as anatomi- 
cally demonstrated by Grainger, in support of the 
truth of the reflex theory, may all evince or be 
affected with morbid sensibility in the periphery, 
or at their origins. 

It was mentioned (p. 18) that sensibility is a 
characteristic property of nerve, and that there is 
no such thing as the " organic sensibility" of Bichat 
independent of the nerves. If, therefore, certain 
diseased states, unaccompanied by pain, termed 
"irritation," exist in a part, of which the spinal cord 
takes cognizance, and which are indicated by sub- 
sequent production of abnormal muscular contrac- 
tions, in distant parts of the body, it follows that 
the spinal cord has become sensible of that diseased 
state, that is, has participated in the morbid sensi- 
bility, although the brain has not been informed of 
it; and therefore, as I know no other term than 
morbid sensibility {susceptibility to impression, im- 
pressibility), equally intelligible and applicable to 
designate the morbid state of the brain, of the 
spinal cord, or of the sensitive, organic, or incident 
nerves, which has been miscalled " irritation," I do 
not hesitate to employ it. 

If the nerves of sensation be rendered morbidly 
sensitive, pain is produced by common occurrences 
which ought not to affect them, such as pressure 
either from external things, or even of the surround- 
ing parts. This morbid sensibility of nerves of 
sensation is not always confined to the nerves of 
the inflamed part, but often spreads to the branches 
of nerves which communicate with them directly, 


or through the nervous centres, thereby producing 
sympathetic morbid sensibility, and pain or tender- 
ness on pressure, &c. It appears to be opposed to 
our knowledge of the anatomy of the arrangement 
of the nervous fibrils (of which there is no anasto- 
mosis, as in the arteries, &c, but merely a juxta- 
position of cylindrical or varicose tubes, as the pipes 
of an organ), as well as contrary to the laws which 
regulate the transmission of impressions, (which is 
generally considered to be only centripetal in the 
sensitive nerves, i. e. from the periphery of the 
body and various internal surfaces and parts to the 
brain), — to assert that sympathetic pains are pro- 
duced by any influence spreading or being commu- 
nicated directly from one branch of a nerve of sen- 
sation to other branches of the same nerve, or to 
different nerves in the same neighbourhood. Never- 
theless, our experience in the observation of disease 
appears to indicate that the communication does 
actually take place ; for instance, sometimes disease 
of one tooth, irritating or disturbing the state of 
one filament of the superior maxillary nerve, in- 
duces pain, not merely in some other, or all the 
dental nerves, and the cutaneous twigs of the cheek 
of the same side, but also in the corresponding 
frontal branch of the fifth, — as, from tooth-ache, 
tenderness on pressure is felt in the temple ; and, 
what is still more extraordinary, pain in the dental 
branches of the opposite side of the jaw, or even of 
the inferior maxilla. 

These morbid sympathies take place without 
inflammation being communicated to the sympa- 
thising part, although sometimes the inflammation 


spreads : as the cheek will swell and inflame from 
the tooth-ache ; the inguinal glands from the ure- 
thra being inflamed, &c. 

True indisputably as the axiom in physiology 
is, that each filament of a sensitive nerve preserves 
its individuality throughout, and that its peripheral 
extremity corresponds to a particular part of the 
cerebrum, which it painfully or pleasurably affects 
whenever it is impressed, — as any given wire of a 
piano, or the air in the pipe of an organ, is set into 
vibration when the particular key it responds to is 
touched, — it still appears incontrovertible, that the 
mass of filaments in a nerve, or nerves, which 
arise in the central organ near to one another, or 
even in those not neighbours at their origin, are 
influenced, to a certain extent, by one another. 
I am of opinion that the diseased state of the 
nerve is communicated to that part of the brain 
where it arises ; and this morbid state, spreading 
to the root of another nerve, whether near or dis- 
tant, causes pain to the individual, which though 
felt in the brain, is referred of course by him to 
the part in which the last-mentioned nerve rami- 
fies (as pain is referred to a paralytic hand, which 
is caused by lesion in the brain at the root of the 
nerves of the hand). This is illustrated by what 
we have said of the concomitant affections of the 
different nerves of the trigeminus. In like manner, 
certain impressions received by the spinal marrow 
affect certain motor filaments, producing involun- 
tary muscular contractions. 

Sometimes the part in which the morbid sensi- 
bility primarily exists may not even be in pain, 


and the irradiations or transfers of morbid sensi- 
bility take place in such cases from parts supplied 
chiefly by the sympathetic nerve, to parts in which 
ramify the cerebro-spinal nerves, as in uterine 
affections we have tenderness on pressure over the 
abdomen ; or in disease of the liver, pain about 
the right shoulder. Here the morbid sensibility 
can only have been reflected via the spinal marrow 
and brain ; or, as I have explained in the case of 
the nerves of the trigeminus, or of a paralysed 
hand, it may not have been reflected at all, but 
produced the sensation by implicating merely the 
roots of nerves. 

If the morbid sensibility be propagated from 
an organ supplied by the sympathetic to a viscus 
dependent upon the same nerve, the explanation 
of the transfer has been considered at all times 
easy, owing to the erratic course and connexion 
between every part of that nerve. 

Again ; the participation of a viscus supplied by 
the ganglionic system, as the heart, in the morbid 
sensibility (with or without pain), affecting a part 
supplied by a cerebro-spinal nerve, as the hand, 
the foot, &c, can only arise from the disturbance 
being conveyed to the brain or spinal cord either 
by the sentient, organic, or incident filaments, 
and from thence reflected to the heart, whereby 
the pulse is quickened in the progress of inflamma- 
tory or other diseases, unless indeed the propaga- 
tion of morbid sensibility in such instances depend 
solely upon the universal distribution of the organic 
or ganglionic system of nerves ; in which case we 
do not require the aid of a separate set of filaments 



(incident, efferent), or the route of the spinal cord, 
to explain the difficulty. 

I agree, however, in the opinion of Muller, 
that the sympathetic nerve, with respect to the 
sympathies, explains nothing ; and that, as the 
ganglionic nerve, viewed apart from the sensitive 
and motor twigs which accompany it in its wan- 
derings, it has nothing to do with sensation or 
muscular action ; and that it is only the nerve 
of vegetative or organic life, presiding over the 
functions of nutrition, secretion, &c, performed by 
the capillaries (which he expresses by the words 
"chemische Processe" and "Stoffwechsel" — Hand- 
bach, p. 648 et seq.)— that it is, in fact, the true 
nerve of the capillaries. It remains to be inves- 
tigated as to how far the true ganglionic nerve 
depends upon the ganglia as its source, and for the 
constant gradual (galvanoid) action which it keeps 
up in the capillaries in every part of the frame, 
and whether there be not communications in it 
throughout equivalent to the anastomoses of arte- 
ries, unlike the cerebro-spinal nerves. 

The statement of Muller, that the ganglions 
are the source of the nervous influence of this 
nerve, and that it has intermixed with it through- 
out sensitive and motor filaments from the cerebro- 
spinal nerves, just as it gives also twigs from itself 
to accompany them, appears to be corroborated 
by the microscopical observations of Ehrenberg 
and others. 

Whether the numerous phenomena of disease 
and functions of health, which have been pointed 
out by Hall and Muller as "reflex functions," do 


really depend upon the existence of distinct orders 
of filaments, described by Hall — " excitor and re- 
flex filaments" — must be confirmed or disproved 
by succeeding anatomists. 

Notwithstanding what has been said of the 
dissemination of morbid sensibility from the brain 
and spinal cord (after it has been propagated to 
them from any part of the body, or has arisen from 
derangement of those central organs themselves), 
it is but an indication by the nerves of its existence 
there — at their roots ; as we cannot suppose the 
nervous centres to be in a state of morbid sensi- 
bility without some of the nerves informing us of 
it : the sensitive nerves by pain ; the organic by 
excited or disturbed function of the organs sup- 
plied by these peculiar nerves ; and the motor by 
partial or general inordinate muscular action. In 
other words, when the pulse is quickened, the heart 
itself is not primarily affected, but merely the 
spinal cord, and the roots of the nerves which go 
thence to the heart. 

Enough, however, has been here stated to ac- 
count for the symptoms both of pain * and of inor- 
dinate action taking place sympathetically, as it is 

* The well-known fact, that years after an amputation of the 
leg, there is a false idea of pain felt in the toes, from morbid sen- 
sibility in the nerves in the stump, illustrates this still more 
strongly, as the apparently sympathising organ does not even 

The dependence of pain on disease at the root of a nerve 
is too often overlooked, and pains of the extremities treated as 
rheumatism or neuralgia of the part, which are caused by disease 
of the brain or spinal cord, as subsequently evinced by the occur- 
rence of paralysis. 



called, without the sympathising organ being dis- 
eased ; as we see, for instance, occur with the 
colon and heart in hysteria and dyspepsia ; with 
the stomach in nephritis, hepatitis, &c. ; with the 
calf of the leg in diarrhoea; with the other muscles 
in tetanus ; and in numerous other instances fami- 
liar to all practitioners, and in which, if recent, we 
apply the remedies to the primarily affected organ ; 
whereas in old cases, where the spinal cord has 
actually become diseased secondarily, besides the 
requisite medicines, we are obliged to apply leeches, 
counter-irritants, &c, over the vertebras. I have at- 
tended many consultations in which discussions have 
taken place as to whether, in cases of distal pains and 
visceral disturbances which had indisputably origin- 
ated from disorder of the uterus, the malady at that 
period were in the spine or not ; the tenderness on 
pressure and percussion over the vertebrae shewed 
plainly enough that the spinal cord was physically 
affected, although at first it had been only sympathe- 
tically, i. e. functionally. In these cases the symp- 
toms, or sympathies, arising from disease of the 
spinal cord itself have been removed by applications 
to the spine; but if care have not been taken to cure 
the latent and deceptive disease of the uterus, the 
morbid sympathies have soon returned, unless, as 
sometimes occurred, the treatment adopted cured 
both spinal cord and uterus simultaneously. 

I must here mention, that I consider nothing 
can be more faulty than the term (local) u stimulant" 
applied to rubefacients, such as cantharides, capsi- 
cum, croton oil, &c, unless it be the application of 
the term " increased action of vessels" to the state 


of inflammation. The former error arose from the 
latter ; for it having been assumed that inflamma- 
tion was increased action, those substances which 
produced the phenomena were called stimulants ; 
whereas, having proved that inflammation depends 
upon a diminished action of the capillaries, it is 
evident that they are relaxants, either directly or 
secondarily, and that the real local augmenters of 
capillary action are, cold, astringents, salines, &c, 
which are also sedatives of the general circulation. 
The terms stimulant and sedative should not be used 
in relation to the local operation of agents upon the 
capillaries, but as regards their constitutional or ge- 
neral effects, viz. upon the heart and nervous cen- 
tres; and when speaking of local effects on capillaries, 
I prefer the terms relaxant and constringent, as I 
have shewn that the substances which are stimulant 
to the heart relax the capillaries when circulated to 
them, and consequently are not local stimulants ; 
and, vice versa, those which contract the capillaries 
diminish the action of the heart. Referring, there- 
fore, to my former proposition, that the nature 
of inflammation is intelligible only by considering 
that the heart and arterial capillaries are acting in 
opposition to each other (pp. 23 and 105), it fol- 
lows that whatever increases the action of the one 
must tend to counteract that of the other. One 
of the great errors in practice has been that of not 
attending sufficiently to whether the indication of 
cure was general — upon the circulation ; or local — 
upon the capillaries. Thus persons have been bled 
to death for some severe inflammation by those who 
had their whole attention turned to diminishing 


the vis a tergo; whereas, by sending a quantity of 
a local constringent, such as antimonial, mercu- 
rial, neutral, and other salts, through the circula- 
tion, the capillaries would have been contracted, 
and inflammation stopped thereby, without shed- 
ding so much blood. I have already shewn that 
these means, besides their local effect, actually di- 
minish the vis a tergo. 

We have another circumstance also to take into 
consideration, viz. that the apparently direct local 
relaxants of the capillaries (" rubefacients," " local 
stimulants,") are only so from intense action ; for 
in a diluted state they are constringent. Weak solu- 
tions of capsicum and mustard are constringents ; 
but when concentrated, produce rapidly the second- 
ary relaxation or inflammation, as explained in 
the production of chilblain by cold ; being, in fact, 
least " stimulant" when they have been thought 
to be most so. 

There is nothing contradictory in these dif- 
ferent phenomena being produced on different 
structures or organs by the same agents, through 
the medium of the same influence of the nerves. 

The action of muscles and of capillaries is pro- 
duced by the influence of their nerves, but in a 
very different manner in each : the muscle is made 
to contract suddenly, analogous to the effect of a 
shock of electricity ;* on the other hand, the con- 

* At p. 17 I used the term "discharged into them," to suggest 
an intelligible analogy ; it remains to be proved, however, whether, 
after the shock, the organ be left plus or minus — that is, whether 
the nervous apparatus has conducted something into or out of it : 
the decision will not affect the above explanation, as the rationale 
remains the same. 


traction of the capillaries is constant, from a con- 
stant operation of their organic nerves, analogous 
to continued galvanic action. In electric and gal- 
vanic phenomena the agent is the same, yet how 
different both in the action and in the mode of pro- 
duction or distribution ; the one being sudden, re- 
quiring a freedom from damp, the other needing 
moisture for its production ; — as the galvanoid 
action of the non-muscular capillaries is increased 
by sedatives, the agents which will stop and destroy 
the action of the heart and other muscles, and vice 
versa. Substances which produce the electroid 
action of muscles, and are hence named stimulants, 
weaken and even annihilate the galvanoid action of 
the capillaries. 

It will now be seen why the stimulants which 
increase the electroid power of the heart stop the 
galvanoid power of the capillaries of the brain. 
Feel the strong bumping pulse of a drunken man, 
whose brain is in a state of childish weakness from 
the relaxant effect of the alcohol upon the capil- 
lary congeries composing the cineritious substance :* 

* The operation of alcohol, electricity, and caloric, on the or- 
ganised union of capillary and nervous tissues, requires still much 
patient investigation. Electricity and galvanism, which have been 
alluded to more than once as curative agents, require great caution 
in their application, lest by the rapid expenditure of nervous influ- 
ence, relaxation, instead of action, be induced. The application of 
caloric even at the present time may be said to be empirical ; and 
as to alcohol, how few years have elapsed since it was discovered 
to be the remedy for the very disease which it induces ! When 
I speak of alcohol, I mean, of course, not in its pure con- 
centrated state, but as it exists in fermented liquors or diluted 
with water. The operation of alcohol on the nerves is transitory, 



— see how much less intoxicating the same quan- 
tity of alcohol is in wine, especially red wines (the 
astringent circulating to the brain with it), than 
brandy and water of exactly the same strength, 
and consequently how well known less injurious 
to the health — excepting in a few cases, where 
wine disagrees with the digestive organs. Observe 
the effect of the constringent sedative green tea 
on the galvanoid capillary action of the brain, 
when, either from stimulants or fatigue, the latter 
has become relaxed, and the individual drowsy ; 
the pulse is weakened, whilst the energy of 
the mind is restored, and continues until, if in 
excess, the astringent — which had at first con- 
tracted the capillaries to a normal state — reduces 
them below that, and the weakness (delirium) of 
inanition ensues ; just as delirium tremens occurs 
in drunkards, when the fermented liquor, which the 
brain had been so long accustomed to, being left 
off, the pulse becomes weak, the capillaries con- 
tract too much ; through which the delirium (tre- 
mens) of inanition takes place, which may be 
removed by the administration of stimulants to 
relax (re-distend) them to their normal state. 

so that any momentary excitement is soon succeeded by the 
relaxation of exhaustion, unless, as explained formerly, the cau- 
tious exhibition of either be modified into a tonic operation. The 
action of these agents on the capillary organisation is temporarily 
stimulant, and consequently exhausting. Sensorial actions are 
electroid — volition, &c. ; so are the sympathies from mental emo- 
tions — blushing; those of the sphincters from terror, &c. The 
labours of the phrenologists will probably throw light on these 
subjects, as well as on the diagnosis of the precise parts of the 
brain diseased in various paralytic and other affections. 


We have uniformly seen that the effect of seda- 
tives is to constringe the capillaries, and in the first 
instance, independently of their effect upon the vis 
a tergo, to diminish inflammation ; so that, however 
necessary to attend to the heart's action as influ- 
encing the pulse,* we must continually refer to the 
local action of remedies on the capillary and ner- 
vous systems when circulated to them. 

We must bear in mind, also, that morbid sen- 
sibility accompanies opposite states of the capillaries 
— either that produced, through over-distension from 
inflammation, by rubefacient relaxants, such as fire, 
cantharides, or capsicum ; or through excessive con- 

* From what has been above stated, we may understand an 
apparent anomaly in the effect of digitalis as a diuretic, which 
was remarked by Withering and others, — that though its effect is 
to lower the pulse, it failed as a diuretic with patients in dropsy 
who had the most strength of pulse and constitution, and acted 
with those who, from the weakness of their pulse, did not seem 
to require digitalis. The cause of this is, that the local con- 
stringent action of a given quantity of the sedative on the weak 
capillaries of the kidneys would of course be most efficacious when 
there was the least injecting force of pulse to counteract it ; and 
what has been here advanced will render it evident why, when 
diuretics fail alone, bleeding, or even active purging, will assist 
them in producing an effect. I may make another observation 
upon astringents as diuretics. It is well known that uva ursi and 
tinctura ferri muriatis are useful for this purpose, when there is 
sand in the ducts of the kidney and ureters, causing by the irri- 
tation of their presence a congested, inflamed, and consequently 
swollen state of the membrane, by which the tube is narrowed. 
The sand causes bloody urine ; here a powerful astringent, the 
muriated tincture of iron, contracts the vessels of the inflamed 
membrane ; and by taking off the swelling, the tube of the duct 
is enlarged, the sand is allowed to pass off, and the blood and 
mucus are diminished. 


traction by sedatives, such as cold, astringents, &c. 
This will lead us to the explanation of the tolerance 
of sedative treatment when there is inflammation 
and fever, but not when there is morbid sensibility 
alone, as in the nervous diseases. When the ner- 
vous influence is deficient in consequence of the 
injury and debility of the nervous system which 
occurs during the symptomatic fever of local in- 
flammation, or during fever from morbid poison, a 
greater quantity of any sedative agent that is capa- 
ble of inducing contractile action of the capillaries 
is required, either to reduce them to their natural 
standard and diminish inflammation, or to bring 
them below it in sound parts, as, for example, 
when we wish to produce morbid sensibility with 
therapeutic intentions, as of the mucous membrane 
of the intestines or stomach by emetics and purga- 
tives, indicated by the desired increase of the peri- 
staltic action, the griping, or the vomiting. 

But when the nervous influence is abundant, as 
in health, a smaller quantity of sedative will pro- 
duce that effect upon the capillaries which induces 
contraction. There is therefore less tolerance of 
medicines in health than in the state of disease for 
which they are indicated, which will explain an 
error into which many have fallen, of over-estimating 
the powers of new medicines :* for instance, a small 
dose of colchicum given, by way of trial, to a stout 

* It must not be supposed that I consider either croton oil 
or colchicum really " new under the sun." We have an accurate 
account of the croton oil in Murray's Apparatus Medicaminum ; 
it was only out of fashion for about a hundred years : and colchi- 
cum was described by Dioscorides as a remedy for gout. 


healthy person, will produce a depression far greater 
than if given to a weak patient labouring under rheu- 
matism or inflammation. A healthy individual will 
be purged by touching the tongue with the cork of 
a croton-oil bottle, not swallowing half of a drop ; 
whereas it will take perhaps two or three drops to 
purge a person who is feverish. This is equally 
the case with sedatives, stimulants, and narcotics. 
It is universally known what large doses of tartar 
emetic may be tolerated in inflammatory and 
febrile diseases, and how little in health, or in 
chronic affections ; as well as the large quantities of 
opium and brandy which are required to produce 
an effect in delirium tremens, gout in the stomach, 
&c. &c. 

The griping of purgatives is accompanied by 
languor, the over-sedatived state of the capillaries 
producing morbid sensibility, but not inflammation 
or pyrexia. No doubt, the excessive application 
of a sedative, as cold, by debilitating the nerves, 
produces inflammation (chilblain) ; antim. tart, 
does the same externally ; and so might exces- 
sive quantities of drastic purgatives internally. 
Still, however, danger from ordinary purgatives, 
which the Broussaians apprehended, does not exist, 
as the peristaltic motion of the intestines prevents 
the continued application of the sedative to any 
one part.* If one grain of cayenne pepper were 

* Exceptions, however, to this occur : thus, in one of the 
numerous post-mortem examinations which have taken place in 
consequence of the exhibition of quack medicines, lumps of half- 
softened pills were found collected in considerable quantity in the 
intestine (colon), where they had produced fatal ulceration of the 
surfaces on which they had lodged. 


applied for some time on the back of the hand, it 
would produce inflammation ; whereas a teaspoon- 
ful is taken by some persons into the stomach with 
impunity, on account of its being mixed with the 
ingesta, and not applied permanently to any spot 
of the mucous membrane. It is the same with 
croton oil, mustard, squill, tartar emetic, &c. 

I feel satisfied that Hamilton's work upon 
purgative medicines was of infinite use, by remov- 
ing prejudices which had been inculcated by some 
of the ancients; and that though it has led to a 
somewhat indiscriminate use of purgative medicine, 
that has been, in the* hands of ignorant persons, an 
error on the safe side, instead of their resorting 
perpetually to opiates, which was the empirical 
mode of giving relief formerly, and by which many 
inflammations were increased — not by the opiate, 
but by the deceitful ease obtained causing neglect 
of antiphlogistic remedies, and thus allowing the 
inflammation to gain ground. One ab.use I con- 
sider too serious, however, to omit mentioning ; it 
is the ill-judged administration of purgatives to 
puerperal females. The uterus, though not in a 
state of inflammation after natural labour, is of 
course in a state of morbid sensibility, and the 
effect of lowering the female by purging is in many 
instances to make her hysterical ; there are then 
induced sympathetic pains of the abdomen, with 
tenderness on pressure, flushed skin, restlessness, 
&c. The inexperienced or ignorant attendant, 
mistaking these inconveniences for symptoms of 
inflammation, resorts to the lancet, and other de- 
pletion ; and the woman becomes more hysterical, 


with increased pain, debility, jactitation, &c. &c, 
occasioning serious embarrassment to the practi- 
tioner, if nothing worse result. Similar evils fre- 
quently arise from the injudicious administration 
of cathartics to hysteric unmarried females. 

Persons who are in the habit of taking open- 
ing medicines injudiciously upon every trifling occa- 
sion find that a teaspoonful of salts acts freely ; but 
we know that, when feverish, it will require four 
times as much, combined also with senna, &c, to 
open the bowels. For the same reason, a very 
small dose of calomel will nauseate a healthy per- 
son ; so that those who dose themselves unneces- 
sarily, and have found calomel " disagree with them 
excessively" when they were in reality well, will 
often beg of their medical adviser not to prescribe 
it for them. The young practitioner will hence 
perceive the propriety of not attending to such 
requests, when his judgment tells him what is 

Delicate people, on the contrary, whose ner- 
vous systems are weak, often exhibit great toler- 
ance of purgative medicines, and constantly resort 
to them ; but a free exhibition of tonics, by 
strengthening the nervous system, will be a much 
better and more certain mode of keeping the 
bowels in order. Stimulants will have the same 
tendency, provided no feverishness exists. The 
subject of administration of tonics is very interest- 
ing as relating to every-day complaints ; such as 
acidity of the stomach, and habitual costiveness. 
Every one knows that an alkali (as soda), or ab- 
sorbent (as magnesia or chalk are called), will neu- 


tralise acid when it has been generated in the sto- 
mach, and relieve for the time ; but the way to cure 
is to prevent the formation of the acid, by tonics, and 
nothing better than by an acid, such as the diluted 
sulphuric acid, three times a day, either alone or 
with quinine or other tonics ; and I have frequently 
cured habitual costiveness by similar means : for 
instance, by a quarter or half a grain of sulphate 
of quinine or of iron three times a day. 

It appears to me that there has been much 
error with respect to the management of the diet 
of dyspeptics. Practitioners often restrain them, 
or they debar themselves, from food which they 
consider very liable to ferment, such as fruit, vege- 
tables, weak wine, and beer. The stomach should 
be cured, and made to digest such food as is fitted 
for it, and presented by bountiful nature. It is true, 
that stomachs which have been debilitated, whe- 
ther by disease or by their natural powers having 
been exhausted by over-feeding, and especially by 
indulgence in the stronger wines and spirituous 
drinks, will permit the development of acid from 
such food ; but this is of little consequence, for 
by perseverance in avoiding alcoholic liquors, and 
in the use of proper tonics, such as bismuth, the 
sulphuric, nitric, and hydrocyanic acids, gentian, 
cascarilla, &c., the most censured articles of food 
above mentioned will form the best, from being the 
lightest, nourishment. Persons who seek to pre- 
vent acidity by introducing into the stomach merely 
plain meat and bread, and drinking dry wines only, 
do not succeed ; for in a short time, even these wines, 
whether port, sherry, or madeira, occasion the for- 


mation of acid ; brandy and water is then tried, but 
to no purpose, as these materials will turn intensely 
sour in the stomach. Moreover, nothing is more 
injurious than this " regularity" of diet, for the same- 
ness of food produces sluggishness of the bowels, 
for which variation of diet is the best remedy. 
Every change of diet, sometimes the use of vege- 
tables, sometimes their omission, sometimes wine, 
sometimes beer, or any other drinks, will prove 
a fresh stimulus to the peristaltic motion, which 
languishes when there is no variety. There are 
no better beverages for dyspeptics than ginger or 
spruce beer, which have the agreeableness of fer- 
mented liquor with scarcely any alcohol. Ripe 
fruits and lemonade do not produce acidity, but 
rather refresh and strengthen the stomach. It 
should be observed, that lemon, though sour, is a 
ripe fruit, and does not disagree, like sour oranges, 
or other unripe fruit. I differ from many practi- 
tioners, in allowing ripe fruit to persons suffering 
from thirst in gouty and calculous diseases. These 
originate in indigestion ; and as vegetables and ripe 
fruit promote digestion and allay febrile heat, they 
rather assist than retard the cure, besides the re- 
freshment they afford the patient. 

From physiological and pathological observa- 
tion we may deduce, that the nervous influence 
produces the three phenomena, muscular contrac- 
tion (voluntary and involuntary), sensation, and 
capillary contraction. We have seen that some of 
these phenomena predominate alternately in dif- 
ferent parts in the natural routine of life, and under 
the control of medicinal and other agents. We 


likewise uniformly see, that when capillary action is 
stopped or diminished, a simultaneous alteration in 
the state of the sensitive twigs which accompany 
the organic nerves of the capillaries is evinced by 
pain, soreness, itching, &c. Capillary action is 
stopped in two ways (independently of mechanical, 
chemical, or other destructive injury) ; viz. either by 
depriving the nerves, and consequently the capilla- 
ries, of influence, as by extra heat, or electricity, 
or by rubefacients, relaxants (called local stimu- 
lants), such as cantharides, capsicum, &c., in a con- 
centrated form, which expend it ; or, on the other 
hand, by increasing capillary contraction by astrin- 
gents, cold, &c. This second cessation of capil- 
lary action arises, not directly from the contrac- 
tion arriving at its utmost ; but inasmuch as the 
capillary action goes on only whilst there is 
blood in the capillaries, we may infer that, when 
they have emptied themselves by contraction, the 
power of contracting also ceases. Excessive action, 
therefore, produces loss of power, and inflamma- 
tion may result ; consequently, after tenderness, 
which is the first step, we should have redness, 
distension, loss of power, — congestion. But if the 
constitution, &c, be in a good state, the temporary 
suspension of function of the capillaries does not 
necessarily produce inflammation, whether the sus- 
pension of function arise from the application 
of considerable heat, or a mustard poultice, on 
the one hand, or from cold, on the other, as we 
may sometimes see the fingers white and dead, as 
it is called, from cold, and yet not subsequently 
inflame, though sometimes they do, producing chil- 


blain. We can understand the rationale of all the 
modifications of sensations which arise — the gentle 
warmth accompanying blushing — the itching of 
diminished capillary action in the skin or other 
part, with congestion or commencing inflamma- 
tion, increased to pain upon still farther diminution . 
of capillary action ; each degree depending upon 
the accompanying impression on the nerves of 

A reference to the direct or sympathetic opera- 
tion of the nerves upon the capillaries will guide the 
surgeon in the application of cold or heat, and ex- 
plain why excess of cold occasionally does mischief, 
instead of putting back a tumour, when applied for 
that purpose. If inflammation exist, as after an acci- 
dent, in a healthy person, or if whilst the reparatory 
process is going on, the injecting force of the heart, 
though natural, be too great for the weakened 
state of the injured vessels of the part, cold usually 
gives relief, by constringing the vessels and dimi- 
nishing the sensibility of the nerves. If, on the 
other hand, from the constitution being unsound, 
or from other causes, there be diminished vitality 
in the part, or a weak nervous system, warmth will 
generally relieve, by assisting the weak nerves 
of the capillaries to keep up the animal heat. 
Goulard is sometimes too sedative. Tincture of 
opium, combined with astringents, is useful as a 
collyrium, in cases where belladonna would be too 
sedative. I have seen the latter prescribed in cases 
of deficient nervous energy, where, of course, it 
produced an increase of the debility, which was sub- 
sequently relieved by the more stimulant application. 


The agents commonly called local stimulants have 
an effect analogous to heat ; for though in excess 
they expend the nervous influence too rapidly, 
so as to produce inflammation of a sound part, 
in moderation they are highly useful in some 
cases of local inflammation, where the nerves are 
languid ; while general (diffusible) stimuli, which 
produce intoxication and raise the pulse, would be 
injurious; as we see exemplified in the effect of 
capsicum in quinsey and scarlatina, in which it is 
highly beneficial to the mucous membrane as a 
gargle, or swallowed, when wine would aggravate 
the accompanying fever, as well as the inflamma- 
tion, by increasing the vis a tergo. This distinc- 
tion is not in general sufficiently understood or 
acted upon, and is the reason why students can- 
not understand how cubeb pepper cures leucor- 
rhcea, gonorrhoea, &c., in which the capillaries 
of the part are in a state of relaxation. From 
this misunderstanding, pepper is frequently for- 
bidden as a condiment in various cases where it 
would be useful in promoting digestion, and pre- 
venting flatulence. In order to shew that pepper 
is not injurious in discharges, I had an artificial 
cubebs made (combining the terebinthinate and 
piperine properties), of two parts of juniper-berries 
and one part black pepper ground together, which 
I prescribed with the same good effect as cubebs, 
and induced some other physicians and surgeons to 
try it also. The beneficial result in several hundred 
cases was the same as when cubebs had been em- 
ployed. One reason why pepper has been supposed 
inflammatory, is, that high living is so ; but that is 


not from the pepper which is employed in the made- 
dishes, but from the wine taken, and over-eating. 
It has been long known that Ward's paste, so cele- 
brated for relieving the inflammation of haemor- 
rhoids, owes it efficiency to black pepper. Many 
are afraid to use cubebs in gonorrhoea ; many who 
do use it would start at the proposal to prescribe 
pepper as above. The quickest and best cure of 
the disease I have seen was one where the patient, 
through a mistake as to the verbal directions given, 
took cubebs in table- instead of tea-spoonsful, three 
times a day, and thus consumed two ounces of 
cubebs, and was perfectly cured, in forty-eight 
hours. This was not a chronic case, or gleet, but 
a recent severe one, with ardor urinae, &c. The 
prejudices of education make us start at novel 
facts ; but in public institutions, where there are 
opportunities of prescribing a remedy ten or twenty 
times per week for years, we can draw inferences 
which may be depended upon ; and when a host 
of facts are brought forward in evidence, credence 
is given to the general principles, which would not 
otherwise receive attention. 01. terebinth, in doses 
of from three to ten drops, in mucilage or emulsion, 
is analogous to cubebs in its action ; and I used it 
for the same diseases, before cubebs was revived, 
like croton oil, from the old pharmacopoeias. The 
ol. terebinthinae sometimes irritates the kidneys ; 
and though this inconvenience may be overcome 
by combining some opiate with it, yet as the latter 
tends to confine the bowels, the cubebs, having 
rather a contrary effect, is preferable to the com- 
bination. Creasote much resembles ol. terebinth. 


in its action, and is even more antispasmodic than 
the terebinthinate essential oils, as we see by its 
efficacy in stopping hysterical and other vomiting, 
of which there have been numerous cases pub- 

We have evidence of morbid sensibility of the 
nervous system accompanying the cessation of ca- 
pillary action, whenever a part, however minute, 
dies. In this instance, not merely the function of the 
nerves in this part is suspended, as above alluded 
to, but the nerves themselves die with their capillaries, 
and this consequent shock to the nervous system 
is evinced by chilliness and shivering. Shivering, 
called rigor, is a most constant accompaniment of 
the formation of abscess, and has usually been at- 
tributed to the formation of pus ; but it is the fore- 
runner of suppuration — not depending upon it, but 
upon the death that precedes it ; for the formation 
of pus is part of the process of reparation ; though, 
if it be confined so that it cannot escape, and be not 
absorbed, it will by its pressure produce additional 

The progress of abscess is as follows : a por- 
tion of cellular tissue, gland, or other inflamed 
part, becomes disorganised — dies, accompanied by 
shivering; the process of reparation by granula- 
tion begins, but as the pus from the granulations 
cannot run off, as when upon the surface, it is 
collected, causing a tumour. If this pus be not 
absorbed as fast as it is secreted, distension takes 
place, and the pressure of the pus, in consequence 
of its fluid nature, will be greatest towards the 
point where there is the least resistance, viz. the 


nearest surface, modified by the bone and fascia 
in the parts. When the pressure towards the sur- 
face is so great as to stop the capillary action of 
the parts pressed upon, another layer of the soft 
parts dies. There is usually a renewal of shivering 
during this progress of the abscess to the surface, 
which is called pointing ; and as the constitution 
sometimes suffers much from this repeated de- 
struction of parts, it might be thought that it 
would be beneficial to anticipate the natural exit 
of the pus by making an opening ; but the ob- 
jection is, that if the pus be not allowed to make 
its own way, at least till it nearly reaches the sur- 
face (during which the floor of the abscess is, under 
favourable circumstances, rising from the growth of 
granulations,) the healing will be a very tedious 
process, owing to the depth of the wound ; though 
this lesser evil must be disregarded if the consti- 
tution be suffering from the renewal of rigors, &c, 
called hectic. Rigors, therefore, may be observed 
in a variety of cases of cessation of capillary action, — 
as when a spot of cellular tissue dies, which is always 
the case in the common boil (furunculus). In car- 
buncle, which is but a gigantic boil, we may know 
when the disease is spreading or burrowing, by the 
patient experiencing a rigor, and on the following 
day it will be found that the margin has enlarged. 
These are the phenomena of abscess, of whatever 
size — whether a pustular pimple, a boil, a car- 
buncle, or a deep-seated abscess arising from various 
causes. In the commencement of erysipelas, in 
which there is a loss or cessation of capillary action, 
though the part does not die, shivering occurs 


before any alteration of the skin is perceptible, of 
which, upon examination, the surface will thus early 
be found tender and painful, as in shingles (herpes 
zoster). That there is often a certain destruction 
of the surface of the rete mucosum, is rendered pro- 
bable by the subsequent separation of the cuticle. 

There is no difference between phlegmonous 
and erysipelatous inflammation: it is the same 
inflammation in both cases ; the difference is in 
degree or situation, and depends on the state of 
the constitution. If there be no death of part, 
there will be no slough — no necessity for the sup- 
puration — but merely desquamation of cuticle, or 
even resolution. The stages from a slight erysipe- 
latous blush to the most violent inflammation and 
sudden mortification do not differ but in degree — 
analogous to the difference in degree of the action 
of fire, from a slight scorch to the actual cauterising 
which instantly causes the death of the part : the in- 
termediate stages resembling the action of a moxa, 
or German tinder, which scorches more or less, as 
may be desired ; producing, as it were, the erysipe- 
latous inflammation, either slight, followed by de- 
squamation, or more severe, with immediate effusion 
of serum or lymph, and separation of the cuticle ; 
and, if still more potently applied, causing a slough, 
as erysipelas sometimes becomes carbuncle, where- 
upon it is called phlegmonous ; the two things 
which produce the sum of the phenomena being 
the injury and the constitution — great injury with 
little debility of constitution inducing the same re-, 
suit as less injury with greater debility. Thus we 
see the feeble Lascars brought into the London 


Hospital with limbs mortified by a degree of cold 
which the English bear with impunity. Again, in- 
flammation, which would be erysipelatous and super- 
ficial in a moderately strong constitution, becomes 
carbunculous or phlegmonous in a debilitated one. 
We also find that the various degrees of the same 
inflammation which arise on the backs of persons 
confined to bed are in proportion to the debility 
of the nervous system. In fine, I repeat, there is 
but one inflammation — loss of power in the capil- 
laries — of all grades, from mere loss of tone to 
actual decomposition — melting away (p. 54). Sub- 
ject a steel spring to a blow-pipe heat, or the power- 
ful agency of a galvanic apparatus; first, you de- 
stroy its elasticity, then it begins to give way and 
bend with its own weight, and lastly it melts : we 
have in these analogous cases a tissue and an agent, 
and we witness similar effects in both, from the 
slightest diminution of tone or tenacity to actual 
decomposition and fusion. 

Although astringents, by contracting the capil- 
laries, usually relieve inflamed parts, yet applied in 
excess they may cause morbid sensibility, evinced 
by pain, and increase instead of diminution of the 
inflammation. The administration of sedatives 
also, in excess, produces morbid sensibility ; as, 
from their taking off the injecting force by di- 
minishing the action of the heart, like blood-let- 
ting, the capillaries in the organs, generally, will 
contract too much, and morbid sensibility result ; 
hence frequent contractions of the heart ; whilst at 
the same time, from the diminution of the circula- 


tion of blood (the appropriate stimulus), each con- 
traction will be weaker. Thus blood-letting often 
makes the pulse quicker but weaker ; so do digitalis 
and antimony under some circumstances ; but their 
effect on an over-acting heart is to make the pulse 
slower. The effect of a sedative or bleeding upon 
the natural pulse is to make it at first slower ; then, 
when morbid sensibility and debility come on, the 
pulse becomes quicker (flutters) ; and in animals 
bled to death, the morbid sensibility produces con- 
vulsions j as occurs also from a poisonous quantity 
of digitalis, or haemorrhage from a wound, or flood- I 
ing in parturition. The rapidity of pulse and con- I 
vulsions from haemorrhage are a beautiful " provi- 
sion of nature;" the heart sends on what little blood 
reaches it, so as to sustain life to the utmost, whilst 
the convulsions of the frame help to propel the j 
blood in the veins towards it. 

The pain in the back or head produced by 
haemorrhage, by the sedative operation of bleeding, 
digitalis, or antimony, is caused by morbid sensi- 
bility from over-contraction of the capillaries, in 
consequence of deficient injection of arterial blood. 
The nausea and vomiting which follow blood- 
letting, or the administration of sedatives, results 
from morbid sensibility of the stomach produced in 
the same way. 

This will account for cathartics being assisted 
by emetics, and both by bleeding : the operation of 
a cathartic is sedative, producing local morbid 
sensibility, and consequently increased peristaltic 
motion ; and if a little ipecacuanha or tartar emetic 
(which are also sedative) be added, the operation 



will be more certain. Bleeding has the same seda- 
tive effect, especially if there be hard pulse from 
inflammation ; but, as mentioned above, does not 
alone produce morbid sensibility, until it reduces 
the pulse below par, though it co-operates with 
the medicines; and, on the other hand, if there be 
diarrhoea from inflammation of the mucous mem- 
brane of the intestines, bleeding will diminish the 
purging by diminishing inflammation ; which ex- 
plains the adage of Celsus, that bleeding relieves 
obstinate purging as well as obstinate costiveness. 

But it must at the same time be remembered, 
that too great a degree of sedative operation on the 
intestines will produce stronger contraction of the 
peristaltic muscles— so strong, in fact, as to close 
the tube by spasm, called colic, which we see result 
in the painter's colic from the sedative effect of 
white lead. An unripe apple, or other fruit, pro- 
duces a similar local sedative impression on a part 
of the colon, so that pain (griping) and spasmodic 
contraction result, by which the offending sub- 
stance and faeces are prevented from passing. It 
is well known that purgatives and other sedative 
treatment will not cure colic ; on the contrary, 
they increase the tormenting griping, with the 
misery of sickness in addition, when administered 
by those who think only of a u stoppage of the 
bowels," and purgatives to overcome it. Stimu- 
lants, with narcotics, the warm bath, and warm 
aromatic drink, with opium, especially in enema or 
suppository, will relax the colicky spasm of the 
intestine, and most likely produce an evacuation 
of the bowels ; but if the latter does not occur, as 



soon as the spasm (of which pain is the evidence) 
has been perfectly quieted, a little castor oil will 
operate. Here, again, we have examples of the 
apparent contradictions which occur in medicine — 
bleeding both opening and quieting the bowels, al- 
laying or inducing morbid sensibility, according to 
circumstances. We see the peristaltic action, the 
office of which is to transmit the faeces, actually 
obstructing their passage, by being inordinately in- 
creased — purgatives adding to the obstinacy of con- 
stipation of the bowels — opium relaxing them : in 
short, the same morbid sensibility from sedatives 
producing the opposite effects of purging and con- 
stipation ; and yet that all these contradictions may 
be reconciled upon rational principles. 

Morbid sensibility, as already mentioned, often 
exists, producing sympathetic pain in another part, 
though none is felt in the seat of inflammation, 
if that be not pressed or moved : as in hysteria, 
and other morbid states of the uterus. Whilst 
the person is at rest, no pain is felt in the uterus, 
it being so situated as not to be annoyed, though 
its tender state is evinced by the slightest touch, 
or even by the pressure on the perinaeum in 
sitting down. In many cases, certain nerves which 
communicate, whether through the central organs 
or otherwise, with those of the uterus, being impli- 
cated, the parts in which they ramify are rendered 
tender on pressure, or painful on motion. Thus 
the sensitive uterus being quiet and protected, its 
nerves are not disturbed, and no pain is felt in 
it, though owing to the sympathetically affected 
nerves of the mtestmes being morbidly sensible 


to their contents and to the peristaltic motions, 
there are constant colicky pains. For the same 
reason, there are pains in the loins from the least 
movement, or in the hip, simulating sciatica, or 
producing apprehensions of hip-joint disease ; the 
parietes of the abdomen do not bear motion or the 
slightest pressure, so that peritonitis is simulated. 
The morbid sensibility in the respiratory apparatus 
produces cough, and through the mechanical irri- 
tation of the latter, even spitting of blood, and 
thus occasions apprehension of consumption ; and 
the motion of the heart causes pain in the left 
side, the most frequent and tormenting of the pain- 
ful sympathies of hysteria. The stomach also is 
morbidly sensitive in these cases,* as well as during 
utero-gestation, so as sometimes to be affected with 
pain after eating, sometimes nausea or sickness. In 
like manner, in some stages of inflammation of the 
liver, that organ lying quiet and protected, no pain 
is felt in it unless it be pressed upon; but the 
patient is annoyed through the morbid sensibility 
communicated to other parts, as, for instance, by 
sickness, dry cough, pain of the shoulder, head, 
&c. Inflammation of the kidney produces sympa- 
thetic sickness, &c, in the same way ; and inexpe- 
rienced persons do not suspect, or cannot find out, 
which is the affected organ, when nausea or cardi- 
algia is the most troublesome symptom (page 2, 

* The term hysteria is not applied merely to those aggravated 
cases which are accompanied with fits, &c, which cannot be mis- 
taken ; but to those slighter cases also in which the derangement 
in the uterus is latent, although it induces urgent symptoms else- 



note). This will shew how most diseases disturb 
the stomach, and consequently the digestion ; but 
in how few cases of indigestion is the stomach itself 
first diseased, though dyspepsia is a most conve- 
nient word, and the poor stomach is blamed for 
faults not its own. Nor is it clear that the digestive 
powers were primarily out of order because blue 
pill cured the disease which had produced sympa- 
thetic morbid sensibility of the stomach, nor that 
the action of the blue pill was particularly on it ; 
for blue pill introduced into that receptacle will of 
course find its way into the circulation, and thus 
to whatever organ is diseased, — which will account 
for the innumerable cases to which it is appli- 

As a third case or degree of disease, let us 
consider the local affections, such as inflammations 
of the eye, lungs, or bowels, &c, when they are 
either too great to yield to the remedies applied, 
or when they have been neglected, thus keeping 
up the morbid sensibility of the nervous system ; 
so that, in addition to the increase of pulse, we 
have other evidence of disturbance in the func- 
tions of the nervous system, and in the digesting 
system, &c. through it. Hence, pains in the head, 
back, and limbs, with lassitude, or a feeling of 
weakness, shewing that the nerves of sensation and 
voluntary action are affected; alteration of temper; 
hurry of thought, not indeed amounting to delirium, 
yet enough to shew disturbance of the functions of 
the brain ; want of sleep; wrong perceptions, such 
as fancying the existence of disagreeable smells ; 


chilliness ; morbidly increased heat of the skin, with 
dryness, which shews want of tone from deficient 
nervous energy, — for as long as the vessels of the 
skin are kept in order by the nerves, the secretion 
of insensible perspiration preserves it cool and soft. 
The digestive system is now also deranged, the sym- 
pathetic nerves partaking of the morbid sensibility, 
as well as the cerebral and spinal nerves, and of 
course the organs supplied by them (p. 121 et seq.) ; 
there is loss of appetite, and imperfect secretions in 
the primae viae, causing thirst, frequently nausea, 
and deranged functions of the intestines — constipa- 
tion, or diarrhoea. The kidneys also evince a loss 
of power, their secretion becoming dark, reddish, 
and scanty, as before explained (p. 38). 

The combination of symptoms here enumerated 
constitutes what is called constitutional disturb- 
ance, or symptomatic fever {pyrexia), from local in- 
flammation ; and we have traced them successively 
from the local injury to the constitutional affection : 
we have observed a part, which we have known 
to be inflamed, deranging the functions of the brain 
and nervous system, and consequently the functions 
of the various organs — the skin, heart, stomach, 
bowels, kidneys, &c. The symptomatic inflammatory 
fever might be called symptomatic synocha. It is 
the same assemblage of symptoms which forms 
Cullen's definition of the idiopathic disease synocha, 
viz. heat much increased, pulse frequent and hard, 
urine red, the sensorial functions but little dis- 
turbed, and the power of voluntary motion dimi- 
nished. The idiopathic synocha sets in, in Cullen's 



words, without primary (or preceding) local disease ; 
that is to say, the symptoms of lesion of the nervous 
system are not preceded by any hurt, or local in- 
flammation, or pain, external or internal; but the 
lesion of the nervous system in idiopathic fever is, 
in fact, the local disease. It is, in my opinion, the 
nervous system itself which, being injured, produces 
synocha, or idiopathic inflammatory fever; as it 
arises in hot climates, and in this country in the 
heat of summer, in labourers exposed to work under 
the heat of the sun ; or sometimes from the oppo- 
site cause of excessive cold, combined with depri- 
vations, excesses, depressing passions, or other 
causes of injury to the nervous system, by infection 
or epidemic influence, as is the case in the synocha 

The treatment in both these fevers, the idiopa- 

* In the year 1831, several cases of fever were published in 
the Lancet, in my clinical lectures, which shew the benefit of anti- 
phlogistic treatment in fever. Besides some cases which corre- 
sponded exactly with Cullen's definition of typhus, there were 
others that were what many at that time called typhus, but which 
did not agree with that definition : they were cases of Synocha 
petechialis, which has since constantly been more or less preva- 
lent in London. I took the liberty of naming it S. petechialis, 
as the term " febris nova," by which Sydenham describes it, is 
too vague. The modification of symptoms is merely one of those 
changes in the constitution of an epidemic which have been so 
well and frequently described by Sydenham. In the numerous 
cases which occurred during 1837, the "constitution of the epi- 
demic" had changed, there being a greater preponderance of 
gastric than thoracic symptoms ; and I may also mention the 
coincidence, that the cases of influenza in the ensuing spring 
had less of the pulmonary or bronchial character than usual, and 
assumed in many instances a marked remittent type. 


thic and the symptomatic, is the same, viz. bleed- 
ing by the lancet, leeches, or cupping ; low diet 
and rest; attention to the bowels; sedative anti- 
monial, or other emetic or diaphoretic medicines ; 
and the use of local applications. If the inflam- 
matory fever have arisen from an inflammation 
which has been brought on by a blow or other 
injury, as a fracture, or from an inflamed tumour 
in the mamma or groin, or an inflamed arm and 
axilla after a puncture of a finger, — local applica- 
tions of leeches and poultices, or lotions, are em- 
ployed : if the inflammation be in the chest or 
abdomen, in addition to general means we must 
use leeches, fomentation, blisters, poultices, &c. 
If the inflammation be in the integuments of the 
face and head, in form of erysipelas, lotions, or 
other similar applications, and blisters should be 
applied close to the part. If it be idiopathic syn- 
ocha, still, along with general remedies, we should 
have recourse to local applications — cold lotions 
applied to the head, with leeches and blisters, &c, 
to relieve the inflamed brain or meninges, if the 
head-symptoms predominate ; or leeches, &c. to 
the chest or abdomen, according to circumstances. 
Sponging the skin with water, either tepid or cold, 
also produces a sedative impression on a large pro- 
portion of the nervous system. 

In the instances hitherto adduced the practice 
is straightforward, and the indications of cure 
evident: viz. to use local applications, to correct 
disordered functions, and to lower the force of the 
circulation, so as to diminish the current of the 
blood into the inflamed part, by blood-letting, se- 



datives,* &c. ; the necessity of which is agreed upon 
by those who look upon the throbbing of the arte- 
ries as an evidence of increased arterial action, as 
well as by those who agree with the opinion which 
I entertain, that it is only an evidence of increased 
action in the heart, and deny that there is increased 
arterial action in inflammation, whether the pulse 
be strong or weak. 

Slight pyrexia (feverishness) will arise, from 
local causes, which must be treated without too 
much attention to the pyrexia, as general remedies 
would exhaust and weaken without affecting the 
local disease ; for instance, that from haemorrhoids, 
teething, intestinal worms, hysteriaf (chronic hys- 

We now come to consider the fourth stage of 
disease, when, after the foregoing, state has existed 
for some time, the power of the nervous system 
becomes exhausted by morbid sensibility, want of 
nutrition, &c. ; and when the heart, though still 
under the influence of sympathetic morbid sensi- 

* It must not be forgotten that the sedative medicines, salines, 
antimonials, mercurials, &c, also reach the inflamed capillaries 
themselves through the circulation (p. 68). 

f I consider the cause of hysterical symptoms to be chronic 
hysteritis, yet by no means frequently requiring the sedative anti- 
phlogistic treatment ; most commonly the tonic antiphlogistic, 
often the stimulant antiphlogistic (p. 105). The chronic hysteritis 
producing hysteria is often as slight, though not so transitory, as 
that which Hunter shewed to accompany conception, but which 
frequently lasts through pregnancy more or less. From not re- 
ferring to this source, the notions entertained of hysteria have 
been very vague. Dr. Addison's little work on this subject con- 
tains much valuable practical information. 


bility, deriving less energy from the debilitated 
nervous system, and being also less nourished, has 
less power to contract, and really becomes weaker ; 
the pulse therefore, though still hard, is rendered 
weaker also. Sometimes the brain, from the 
same causes, becoming inflamed, or at least con- 
gested, has its functions more impaired, and the 
thoughts become more confused, until actual stupor, 
or delirium, succeeds ; and the pulse, losing even 
its hardness, becomes soft and weak. The heart 
being now unable to empty itself, the circulation 
through the lungs is retarded, and there is a ten- 
dency to congestion, from their capillaries being 
also deficient in power : the blood therefore not be- 
ing purified, causes still greater stupor, and the pa- 
tient is said to be in a state of typhoid (stupid) or 
low fever ; instances of which may be seen in local 
inflammations from disease or injury, as when there 
is inflammation in the chest or abdomen, or after 
wounds or operations, where the sympathetic fever 
becomes typhous (typhoid). But if the brain does 
not become inflamed or congested, the patient may 
die from mere exhaustion, with all the senses per- 
fect, as in hectic fever. 

Or, we may see a patient with symptomatic 
typhous (typhoid) fever, without having had any 
previous strength of pulse, and with a cool skin, as 
from local injury; when, for instance, with the injury 
the nervous system has received a shock, as in the 
case of a severe accident or of an operation. Thus 
we may trace the progress from smaller injuries 
and their consequences to greater ; a slight inflam- 
mation with morbid sensibility, as a single inflamed 


hemorrhoid, produces shivering, and heat of the 
skin, feverishness {pyrexia) ; the spreading of this 
inflammation to a greater portion of the intestine 
producing symptomatic inflammatory fever (sympto- 
matic synocha) ; and a still further extension of the 
mischief, general inflammation of the bowels, will 
bring on typhoid fever, with oppression of the sen- 

Now, by a similar series of events, the synocha, 
or idiopathic inflammatory fever, may also become 
typhous, which is Cullen's synochus, a fever " be- 
ginning with synocha and ending with typhus."* 
Cullen therefore divided unnecessarily, according 
as it might terminate, one fever into two. It is 
the " common fever" of this country, Sydenham's 
" new fever," the synocha, or S. petechialis, which, 
whether the petechise be visible or not, ought never 
to have been called synochus, much confusion hav- 
ing arisen from the use of this term. 

We have what is called idiopathic typhus with- 
out any previous " synocha," and with the temper- 
ature, from the beginning, even below the natural 

* It is a common error to think that strength of pulse neces- 
sarily exists in synocha. The term synocha does not even imply 
it, as its Greek signification is merely, continued; neither has rv<pog 
(typhus) any reference to the state of the pulse, but merely to 
that of the sensorium. Hippocrates applied it to a stupid or co- 
matose state, in which the patient stares without answering, like 
a person who is haughty or proud, which is the meaning ofru0oe: 
the other possible derivation, tihjjoj or rv^u/xat, having reference 
to a half-kindled smoking or smothered fire, which could only 
allude to the low temperature of low nervous or typhous fever, 
in opposition to the calor mordax of inflammatory or synocha 


standard ; as when the brain and nervous system 
are poisoned by contagion, or by concentrated foul 
human effluvia, as in gaols, transport or slave ships, 
&c, either with or without predisposing circum- 
stances of over-fatigue of body or mind. Is typhus 
or typhous fever inflammation of the cineritious sub- 
stance, and synocha inflammation of the investing 
membranes of the nervous system ? — analogous to 
the difference between inflammation of the sub- 
stance and membranes of other organs, as between 
peripneumony (inflammation of the substance or 
parenchyma of the lungs) and pleurisy (inflamma- 
tion of their membrane), enteritis (of the intestines) 
and peritonitis (of their investing membrane), &c. 
&c. Inflammation of substance more completely 
interrupts the function of an organ than that of 
the membranes, though inflammation of the mem- 
branes produces disturbance of action and pain. 
In typhus, we see the functions of the nervous 
system, thought, volition, and sensation, especially 
interrupted. The difference may, however, consist 
merely in the degree of inflammation or of con- 
gestion of the cineritious substance. 

Typhus and typhous disease are generally con- 
sidered more difficult to treat than synocha, the 
indications of cure more complicated, if not con- 
tradictory ; and medical practitioners are more at 
variance in their mode of attempting to remove 
the symptoms. Here, however, as in the former 
instance, attention must be paid to the local affec- 
tion ; but, above all, in the idiopathic typhus, 
lotions to the head, to constringe and give tone to 
the vessels of the brain, and leeches to relieve the 


congestion, are the essential local applications, and 
the most unequivocal remedies in our power. Be- 
sides local applications, due attention must be paid 
to the alvine and renal secretions : but the most 
important question is, as to the administration of 
stimulants, or of sedatives and depletion ; and it is 
only by careful observation of actual disease at the 
bed-side that we can arrive at the knowledge neces- 
sary to guide us. 

Those (the Brunonians) who looked upon the 
typhous state as one of debility (which it really 
is), but considered only the effect which stimulants 
would have on the healthy frame, and that they 
are often useful and necessary in surgical and other 
cases, where there is much debility, resorted to 
wine and tincture of opium in typhus fever, not 
considering that the disease always included a dis- 
eased state of the brain and nervous system, and 
that though, in some instances, the stimulant might 
be borne with impunity, yet, that by increasing the 
action of the heart, the vessels of the brain, spinal 
cord, &c, would be still more injected, independ- 
ently of the specifically injurious effect of the sti- 
mulant on the capillaries of the cineritious substance. 
In fact, experience proves that cold to the head, 
with moderate saline and other sedative medicine, 
will cure typhus, or prevent the typhous state from 
occurring in synocha ; whereas when wine, with or 
without opiates, is employed, the disease frequently 
proves fatal. I had one very useful opportunity of 
seeing the contrast of the different modes of prac- 
tice during the fever which prevailed in Italy in 
1817, the proportionate mortality being very much 



greater in an hospital where the stimulant practice 
prevailed than in that under the direction of Dr. Agli- 
etti, in Venice, who, I suppose out of compliment, 
called his manner of practice the English, consist- 
ing of " contra-stimulants" (sedative evacuants), 
antimony, salts, purgatives, &c, internally, with 
the external application of cold water and free 
ventilation. But though the British may have 
commenced a similar practice at the same time, 
the adoption of sedative ("contra-stimulant") treat- 
ment in typhus was not introduced into Italy by 
them, but by Rasori ; and that, too, in opposition 
to the stimulant Brunonian practice which he had 
learned in Britain. 

We may understand the risk of stimulating a 
typhous patient, by supposing that when an im- 
portant organ, such as the lungs or brain, is in- 
flamed, or even congested, the weak pulse of the 
typhous state of collapse, during peripneumonia or 
typhus, may be one of the provisions of nature to 
allow the parts to recover, as they would during the 
collapse of syncope produced by bleeding ; and, of 
course, when so important an organ as the brain 
itself is diseased (as it is incontrovertibly in the ty- 
phoid state), we should be careful how we set the 
heart pumping more forcibly than necessary. The 
opposite extreme should not, however, be adopted, 
and the patient be permitted to die for want of a 
spoonful, or even a bottle of wine or brandy (for the 
quantity must be relative, depending on the effect), 
if there be real danger of sinking at an advanced 
period of the disease ; and when the rallying point 
is gained, caution is necessary not to push them 


too far. There is languor and lassitude in all 
fevers ; but the symptoms of sinking, requiring 
stimulants, are, fluttering, weak, soft pulse ; cold 
sweat ; lying on the back ; respiration oppressed ; 
involuntary dejections. Wine, on the other hand, 
will not agree whilst the pulse is hard or sharp, 
and the skin decidedly dry, even when there is 
subsultus tendinum and prostration. Ammonia 
should be tried before resorting to wine.* 

The functions of the primae viae are so uni- 
formly disturbed in fever (symptomatic or idio- 
pathic), that it is not surprising that Broussais, 
an accurate observer, should have fixed upon the 
mucous membrane of the stomach and bowels 
as the seat of the immediate cause of idiopathic 
fever; but I think it has been satisfactorily shewn 
that fever is lesion of the nervous system — if 
commencing there, idiopathic ; if induced there 
by inflammation of other organs, symptomatic. 

* 1 have not mentioned ammonia as a part of the treatment 
of the Brunonians, though it was used by them along with 
wine and tincture of opium ; because ammonia is not, like these, 
a diffusible stimulant. In the first place, ammonia is used em- 
pirically by the most able of the profession, in cases where they 
know from experience that they must not employ wine or tinc- 
ture of opium. This alone shews that it is not really a diffusible 
stimulant — it is a local one ; and as such, through the medium 
of the solar plexus, excites the heart momentarily, though not 
injuriously. Again, so far from being a diffusible stimulus, it 
immediately unites with animal acids, and then circulates or is 
diffused, not as a stimulant, but as a sedative saline ; so as to per- 
form the double operation of a temporary local stimulant to the 
stomach and heart, and a sedative to inflamed capillaries else- 
where, although the latter indication be not contemplated in its 


Some inflammations of the viscera arise during 
fever, and are very truly said to be produced by 
the fever ; that is, the organ having been predisposed 
to disease, when robbed of its due supply of ner- 
vous energy by the derangement of the functions 
of the nervous centres, its vessels fall into the 
congested or inflammatory state ; and when the 
cerebral symptoms diminish, if not before, it is 
observed to be affected. This is the case most 
frequently with the mucous membranes of the in- 
testines and lungs in temperate climates, and with 
the intestines and liver in hot climates ; so that 
many doubt whether the fever produce the hepa- 
titis, or the hepatitis the fever ; or whether the 
inflammation of the mucous membrane induced 
the fever, or the fever the inflammation of the 
mucous membrane, as in acute dysentery. Some- 
times the disease in the first instance is the fever ; 
but even then the brain has been rendered more 
susceptible of the exciting causes of fever by the 
previously debilitated state of the organs — the 
liver, the bowels, or the brain itself; and the mo- 
ment the fever begins, the inflammatory or con- 
gested state of the organ is increased and rendered 
evident, though previously latent. 

From the very nature of fever, which I have 
described to be a disease essentially affecting the 
whole nervous system, it follows that the functions 
of the viscera must be disturbed ; and though, as 
just pointed out, sometimes disease of one organ 
predominates, sometimes of another, yet every or- 
gan suffers more or less congestion in every fever, 
from the loss of nervous influence. Hence those 



who are advocates for fever being a something 
that pervades the whole system, say, you cannot 
refer it to any one fixed seat ; and, on the other 
hand, those who have taken up the notion of fever 
being located either in one organ or in another, 
seldom or never fail, in post-mortem examinations, 
to find proofs of their own opinions ; for, as no 
organ escapes disease, that which is sought for will 
be found, whether the opinion of the author lead 
him to anticipate " cerebritis," ' ' gastro-entiritis," or 
"pulmonic congestion." The temporary conges- 
tion of organs during the febrile state affords an ex- 
planation of the obstinacy of some agues : in bark 
and arsenic we possess certain remedies for the 
poison of simple ague ; but when cases resist these 
means, practitioners resort with success, one to the 
lancet, another to mercurials, a third to leeching 
the epigastrium, &c. The cause which prevents 
the cure of the ague is visceral disease, which may 
either have existed before the intermittent, or have 
arisen during its continuance. The ague and vis- 
ceral disease, whether of bowels, liver, lungs, or 
spleen, &c, act reciprocally as cause and effect — 
the ague aggravating the visceral disease by caus- 
ing congestion during each paroxysm ; the visceral 
disease, by keeping up morbid sensibility during the 
intermission (or even a pyrexial state between the 
paroxysms., when the disease is named remittent), 
which prevents the cure : but if, by mercury, or 
bleeding, &c, the visceral disease be removed, the 
cinchona exercises its influence on the nervous 
system, and finally arrests the disease.- 

We can understand the origin of the former un- 


just prejudice against bark. Physicians found that 
visceral disease sometimes remained after ague was 
cured, which was attributed to the bark " causing 
obstructions ;" and it must have often been fortu- 
nate for a person suffering under a combination of 
visceral disease and ague, that, from the bark fail- 
ing, recourse was had to mercurials, or to those 
remedies which cured the visceral disease, but 
which many called helping the bark. In this 
manner arsenic often acts as equivalent to a union 
of bark and mercury ; for arsenic, besides its tonic 
effect on the nervous system, increases the secretion 
of bile, and otherwise acts on the liver : it possesses 
also the power, like mercury, of curing chronic 
inflammations ; and even farther resembles it in 
occasionally producing the inconvenience of sali- 

Considering disease, then, as depending on the 
conjoint affection of vessels and nerves, and know- 
ing what agents will influence their actions, we 
may in our practice always have a reason for the 
application of remedies, and be able to combat 
such cases as we may not have before seen or 
heard of. Acute diseases are those in which the 
feverish or other constitutional symptoms are the 
most urgent, threatening life. Chronic diseases 
prove fatal only when the gradual alteration of 
some organ undermines the constitution by inter- 
rupting some of the nutrient processes — as in hec- 
tic or marasmus, from disease of the mucous mem- 
brane of the intestines, or from slow disorganisation 
of the lungs, liver, &c. 



Men who consider themselves opposed to each 
other in theory, coincide nevertheless in the essen- 
tial points of practice ; as Armstrong, Broussais, 
Clutterbuck, Frank, Hamilton, Rasori, Stieglitz, 
Tommasini, and others. The object being to dimi- 
nish local inflammation, congestion, or by what- 
ever name the local disease may be called, and to 
counteract the derangement in the organs of circu- 
lation and digestion, all agree upon the necessity 
of rest, diet, and unloading the lower intestines ; I 
might perhaps say, that all agree upon the pro- 
priety of abstracting blood, either by leeches or 
otherwise : they differ as to the use of drugs. 
Broussais says that the others irritate the mucous 
membrane by emetics and cathartics, though he 
does not entirely neglect to empty the bowels by 
enemata ; but as this mode of opening the bowels 
does not produce such a sedative controlling influ- 
ence on the circulating system, &c, as the cathartic 
and emetic substances, he is obliged to abstract 
more blood by venesection or leeches. The others 
may object that this loss of the pabulum vitse does 
more harm than the drugs. One man treats fever 
by venesection, leeches, diet, and scarcely any me- 
dicines : another by abundant use of them (calomel, 
&c), with external application of cold water, and 
perhaps the extraction of little or no blood. One 
man deprecates blisters, because he may have seen 
them applied by very unskilful practitioners, and 
put on in pairs in cases where the patient died in 
consequence of other causes ; but we almost all 
know that blisters are useful in very many cases. 
There are medical men in this country who appear 


to me almost to coincide with Broussais in his 
opinion as to medicines irritating the mucous mem- 
brane, and who object strongly to repeated doses 
of calomel and purgatives in febrile complaints, and 
say that emetics act on the principle of counter- 
irritation. It is interesting to observe how various 
writers confirm my opinion of emetics being seda- 
tives, and the practice of the " new Italian school," 
which considers them to be contra-stimulants acting 
like venesection in controlling the circulation ; as 
Clutterbuck, for instance, says, that he "found 
emetics have a beneficial effect, before he knew 
the value of venesection in fever." 

The state of low or typhus fever being in reality 
debility, it is difficult for the beginner to satisfy 
himself of the necessity, or even the safety, of using 
depleting sedative remedies : nevertheless, all who 
have experience (except the Brunonians) allow its 
expediency, in whatever way they may explain it ; 
and it is necessary to be as well assured as possible 
on this point. The student can more readily be 
convinced of the necessity for depletion in a state 
of complete prostration produced by inflammation 
of the lungs or other organs ; because he can un- 
derstand the cause of that state to be, that the 
capillaries of the organ are overloaded, and that 
by lightening them, their power of action may be 
restored. But the low fever being thought to have 
no fixed habitation, and being considered as a 
something pervading the system, the rationale of 
treatment is found not so evident. Fever pervades 
the frame, it is true, because the nervous system, 



which is its seat, pervades it. The phenomena of 
idiopathic fever shew that the nervous system is 
first implicated — debilitated by a morbid poison 
from the first : hence the necessity for unloading 
the debilitated congested capillaries of the nervous 
centres by sedative treatment (p. 68,1. 14) : in addi- 
tion to this, as post-mortem examinations prove 
that there is uniformly more or less visceral inflam- 
mation accompanying typhus, the expediency of an 
antiphlogistic treatment becomes more obvious. 

Although the fevers produced by local inflam- 
mations, symptomatic fevers, closely resemble the 
idiopathic fevers produced by infectious effluvia, 
there is in the latter an immediate impression on 
the nervous system, caused by the morbid poison 
of the infection, independently of the inflamed or 
congested state of the capillaries of the nervous 
centres, which exists alike in both symptomatic 
and idiopathic fever. And though symptomatic 
inflammatory fever may resemble idiopathic in- 
flammatory fever as much as the inflammatory 
eruption produced by tartar emetic resembles the 
idiopathic eruption of small-pox, yet there is more 
lesion of the nervous system in idiopathic than in 
symptomatic fever : there is, as it were, some che- 
mical or electric effect produced by the poison ; 
and the duration of the violence of the fever ap- 
pears to be in proportion to the power of the dose 
of poison received. We see that one morbid poison 
produces fever followed by small-pox eruption ; 
another produces fever followed by the carbuncles 
and abscesses of plague ; and that the severity of 
the disease is proportionate to the dose of the poi- 


son, allowing for the state of the constitution ; for 
there is mild plague, as well as mild small-pox, or 
mild Asiatic cholera ; there being all degrees of 
those diseases, from that which kills in three or 
four hours, to that which never confines the pa- 
tient to bed, but allows him, on the contrary, to 
attend to his business with a carbuncle, or inguinal 
or axillary abscess of plague ; or a few spots of 
eruption of small-pox ; or the diarrhoea of slight 
cholera. Continued fever, remittent fever, and ague, 
also differ in degree according to the strength and 
dose of the poison — from the mild ague, synocha, 
or typhus, to those severe cases which prove fatal 
in a few hours ; from the mild agues and remittents 
of this country, to those of hot climates, which are 
fatal in the first, second, or third paroxysm. If the 
dose of poison has been too great, it will stop the 
machine, unless remedies can be applied to relieve 
the parts most oppressed, until the nervous system 
recovers sufficiently to renew or re-secrete that 
influence, the power of doing which is diminished 
by the poison, and without which it cannot impart 
energy to the organs. 

One thing necessary to the recovery of the 
nervous system is arterial blood : to produce this 
of a good quality, digestion and free respiration 
are requisite ; yet, in fever, from the loss of power 
in the nerves, the process of digestion is imperfect, 
and the lungs become congested. 

The digestion having been disturbed in the first 
instance, the food which was in the bowels becomes 
thereby spoiled, and must be removed by purga- 
tives, as from its undigested state it cannot furnish 


good nourishment, even if it do not prove a source 
of irritation : it is therefore useless to supply other 
than fluid nutriment (I have found milk the best), 
until some renewal of nervous energy takes place. 
This restoration of nervous energy will not be ex- 
pedited by stimulants; for in whatever way the 
cineritious tissue generates nervous influence for 
the supply of the medullary, time is required for 
the process, as during sleep. Experience teaches 
that stimulation, except during a state of inanition, 
only oppresses ; whereas it is acknowledged that in 
fever the opposite state of the capillaries exists — 
plethora, active or passive. The lungs being con- 
gested, it is useful to take away some blood, by 
which the remainder is better arterialised, and is 
thus more adapted for the restoration of the ner- 
vous system ; besides which, there is in inflammatory 
fever a direct indication of the necessity of bleeding, 
to relieve the inflamed parts, whether the brain it- 
self or other viscera be the seat of the inflammation. 
As in typhus fever, from the nervous system 
and the functions of digestion, secretion, circula- 
tion, and respiration being weak, universal debility 
appears to exist, great difficulty is experienced in 
rendering the advantage of bleeding and other 
sedative remedies evident. But how different is 
the sudden functional debility in fever from that 
real debility of the frame induced by starvation, 
wasting disease, loss of blood from a wound, &c. ! 
Febrile debility is relative, in consequence of which 
the ordinary quantity of blood in the system be- 
comes disproportionate and oppressive, more espe- 
cially as it is at the same time deteriorated. 


Under these circumstances, the object is to 
restore the strength of the nervous system ; stimu- 
lants, however, do not effect this, but, by temporary 
excitement, tend still farther to exhaust it : a gra- 
dual supply of arterial blood can alone suffice for 
its recovery. Were we even to suppose that the 
heart were still capable of being stimulated to 
increased action, it is evident that increased 
action only tends to overload the congested capil- 
laries of the brain with blood, which, from the 
congested and adynamic state of the lungs, has 
been less perfectly arterialised, as is shewn by the 
lividity of the lips, dusky colour of the skin, &c. ; 
oppression of the nervous system is thus increas- 
ed, and matters aggravated, so that the animal 
powers necessarily begin to decline. But the heart 
is not always capable of being stimulated to in- 
creased action — it is really weak in typhus, from 
deficiency of nervous influence ; stimulants may 
increase its sensibility to the presence of the blood, 
causing it to make more, though inefficient, effort ; 
so that it struggles against an overload, and thus 
only becomes more exhausted. As stimulants do 
not give power, but only elicit that which exists, 
the entire system, and the heart in particular, in 
typhus, may be compared to a tired horse in a 
loaded cart, reaching the foot of a hill, but unable 
to ascend it : the stimulus of the whip may make 
him struggle to the attempt, but, if urged, he will 
at length sink ; if, however, some of the load be 
removed, he can ascend the hill : and if some of 
the load of blood be withdrawn, the pulse will rise, 
as is well known and admitted in its sunken state 



in severe inflammation of the lungs or bowels, but 
which is not so generally acknowledged in typhus, 
where bleeding is, nevertheless, sometimes resorted 
to, either on account of the fever itself, or some of 
the " complications" of local inflammation of the 
head, chest, or abdomen.* But, again, if the horse, 
without being either stimulated by the whip or 
having his load lightened, be allowed to rest, he 
will be able to ascend; and thus often without 
either stimulating on the one hand, or venesec- 
tion on the other, the heart will recover, and the 
pulse rise. 

This leads to the explanation of the manner in 
which saline, antimonial, and other sedative or 
antiphlogistic medicines, and means, such as cold 
externally, and bleeding, are beneficial in fevers, 
both where the pulse is too strong and where it is 
too weak and rapid. In both cases, sedatives, by re- 
pressing the expenditure of nervous influence, cause 
the heart to struggle less, and take repose. At the 
same time, the action of the capillaries throughout 
the frame being increased, by the constringing pro- 
pertyf of the sedative circulated to them, the ner- 

* Much valuable information on this subject may be obtained 
from the work on fever by Dr. South wood Smith. 

f I have formerly spoken of the tonic operation of mercury in 
chronic diseases : its antiphlogistic property in acute inflamma- 
tion is also universally acknowledged, which antiphlogistic pro- 
perty I call sedative ; and as a sedative, it is by many considered 
most valuable — nay, indispensable — in bad fever. It is highly 
valuable, but not so much so as antimony and the neutral salts, 
and certainly not indispensable. To prove this to my pupils, 
as some were to practise in the naval or military service abroad, 


vous system recovers power. Thus febrifuge seda- 
tives diminish the coma of plethora which exists in 
typhus, and which results, not from over-power of 
the heart, but from weakness of the capillaries of 
the nervous centres ; and it is thus that they be- 
come powerful allies of bleeding, or even substi- 
tutes for it, in cases and stages where bleeding is 
either not necessary, or contra-indicated. 

Thus we witness the operation of two modes 

and might have the misfortune to be left without calomel, I 
undertook to shew them how to cure fever without its assist- 
ance, and took the next dozen of cases as they occurred — some 
very bad, some middling, and some slight. We lost but one, an old 
person, who had very mild fever, but died of a previously diseased 
state of the lungs, as we ascertained by post-mortem examina- 
tion. This was no experiment, but a demonstration of the truth 
of principles well established. The remedies employed in these 
cases were, in some bleeding, in all tartar emetic, with sulphate 
of magnesia and senna in addition, when required. 1 commonly 
use calomel with the other medicines in fever, when indicated as 
already explained in various passages ; but one medicine may be 
substituted for another. It is proverbial that an experienced work- 
man does not find fault with his tools : if a carpenter have broken 
or lost his chisel, he can use his plane-iron for the moment as an 
efficient substitute. I here rather wish to point out the abuse of 
calomel, and salivation by mercury, by those who consider mercury 
as a specific for fever. In the first place, it requires more time to 
affect the system by mercury than by tartar emetic and salines, &c. ; 
so that some cases are saved by the prompt use of antimony, bleed- 
ing, &c, which would not have waited for mercury. I have seen 
the other useful means overlooked in the treatment of fever, by a 
too exclusive attention to mercury. And I may add, that however 
valuable mercury is in all stages of peripneumonia, we know well 
that we cannot wait for its action in the acute stages without 
employing other active sedative treatment, especially bleeding and 
tartar emetic. Again, salivation puts the patient to very unneces- 
sary inconvenience, independently of the weakness produced by 
its prolonging the convalescence. 


of diminishing the exertions of the heart, the neces- 
sity for which is universally acknowledged when 
the pulse is too strong and frequent ; but it is not 
so generally acknowledged that when the pulse is 
frequent and weak, the heart is also over-exerting 
itself. It should be, however, remembered that in 
each case the blood is not only the load which is 
to be moved by, but the excitant of action to, the 

The diminution of organic action in the heart 
by sedatives diminishes its efforts equivalent to re- 
ducing the quantity of blood ; and it is obvious to 
every one who has observed or felt the effect of a 
dose of salts, or of an emetic on the pulse, that this 
is the effect produced on the heart by salts, anti- 
mony, and other emetic and purgative substances, 
as well as by digitalis, prussic acid, and other seda- 
tive remedies. The operation of cold drink, or of 
cold externally, is also sedative; as is shewn by 
persons who, when exposed to inclement weather 
in travelling, can, though unaccustomed to stimu- 
lants, swallow brandy, which, under ordinary cir- 
cumstances, would produce a sense of burning in 
the throat, and intoxication. By the continued 
application of intense cold, as when persons have 
been lost in the snow, the sedative effect on the 
nervous system and heart produces total loss of sen- 
sibility* (miscalled sleep), and death by asphyxia. 

* When cold is applied to the head in fevers, &c, by means 
of pounded ice in a bladder, the medical attendant must himself 
from time to time watch its effects ; of which the best nurses 
even in hospitals are not capable of judging. This applies especially 
to cases in which the patient is insensible. In all cases except 


Although emptying the prima? viae by purga- 
tives and emetics is useful in fever, it is not merely 
to the evacuating properties, but also to the seda- 
tive and constringent effects of those medicines 
that the benefit is attributable; and of this we 
have sufficient proofs. First, antimony controls 
fever, without either producing vomiting or purg- 
ing, of which we are aware in the present day, 
when we use small repeated doses of tartar 
emetic, with or without salines, as a " febrifuge" 
medicine. Again, James's powder was formerly 
much used for the same purpose, and it was 
a common observation, that it appeared often 
most efficacious where it produced no evacuation 
of vomiting or purging : perspiration cannot be 
called an evacuation, as it is only an evidence of 
returning function of the skin from decline of the 
fever. The saline medicines appear (besides their 
constringing effect on the capillaries) to have some 
influence in giving to the blood that arterial pro- 
perty (colour at least) which is so connected with 
nervous energy. Armstrong and Clutterbuck em- 
pirically confirm the benefit of sedatives in fever, 
without having accounted for their action. Arm- 
strong was, however, one of the few persons who 
thoroughly understood the use of digitalis as an 
antiphlogistic or sedative remedy. 

In surgical cases the symptomatic fevers often 
require antimonials to cool them ; and though sur- 
geons have employed emetics to promote the ab- 

maniacal affections, the cold should be removed, temporarily at 
least, when it ceases to afford sensation of relief, and becomes 
evidently disagreeable to the patient. 


sorption (as they say) of abscesses when formed, 
they are not sufficiently in the habit of resorting to 
antimonials to prevent the mischief of their forma- 
tion. The rigors, burning skin, and pain in the 
glands of the groin or axilla, from puncture or 
other injury of the toe or finger, may be cut short 
in the course of an hour or two, by an emetic, 
which removes the above symptoms, produces per- 
spiration, and prevents abscess : the sedative influ- 
ence should be maintained for twelve or eighteen 
hours by an eighth or a sixteenth of a grain of 
tartar emetic (=xv. or xxx. drops of vin. ant. tart.) 
every two hours, or just sufficient, according to 
the stomach of the patient, to keep up the influ- 
ence without causing the inconvenience of sick- 
ness.* Lind, when speaking of the destructive 

* A young surgical friend called me one evening to see his 
brother, saying that he had fever, and so much shivering and oc- 
casional bursts of perspiration, that he feared it would turn out to 
be small-pox. I saw at once, by the patient's eyes, that it was 
not idiopathic fever of any kind. On inquiring if he had not 
hurt his foot or hand, he said he had run a splinter into his mid- 
dle finger the day before ; but that he had been so wretchedly ill 
all day with headache and shivering, that he had never thought 
of that, so as to mention it to his brother. There were already 
red streaks up the back of the hand, slight swelling, and great 
tenderness, on pressure, in the axilla. I prescribed an eighth of 
a grain of tartar emetic every quarter of an hour until vomiting 
should come on, and afterwards every two hours until the ten- 
derness should subside, or half the quantity, if it should produce 
more than very slight nausea. The second dose produced the full 
emetic effect, with instant relief of the headache and of the rigors, 
which never returned ; and when I called the next morning, he 
had no pain in the axilla. The red streaks of the lymphatics on 
the wrist remained, which will suffice to remind any surgeon 
what might have been expected, if the inflammation had not been 


fevers of Senegal, describes the power of an emetic 
in arresting the fever ; but complains that an eme- 
tic failed of producing so good an effect on the re- 
turn (exacerbation) of the fever the following day. 
Had the influence been kept up as just described, 
with bark in addition, the fever would have been 

The successful practice of Broussais is a proof 
that the sedative effect of abstracting blood, watery 
diet, and withholding stimulants, can operate suffi- 
ciently in many instances, in spite of what others 
call his neglect of the bowels. At the same time 
that this is conceded, gastro-enteritis cannot be 
considered the cause of idiopathic fever ; though it 
is true, as was shewn above, that in every instance, 
from the secondary loss of tone of the primae viae, 
and consequent unnatural state of their contents, 
more or less gastric morbid sensibility, congestion, 
or even inflammation of their mucous membrane, 
of the glandulae agminatae, &c, must be a constant 
concomitant of fever, as, in fact, dissection proves. 
Arguments drawn from successful practice are 
sometimes fallacious ; the cure of fever, by abstract- 
ing blood from the abdomen by leeches is no proof 
of gastro-enteritis being the proximate cause of 
fever ; any more than that the seat of the disease is 

cut short. I have pursued the same practice in other similar 
cases, with equally rapid and decided relief. When pupils punc- 
ture their fingers, they often apply caustic, which is very bad 
treatment of the wound. The best plan, if the finger be hot and 
painful, is to keep it in a basin of cold water, and to take tartar 
emetic in the manner just mentioned, which will soon allay 
throbbing, inflammation, &c. • 


in the arm, if cured by taking blood from that part. 
I once met with a publication asserting that the 
seat of hooping-cough (pertussis) was the head, 
because leeching the temples relieved it : leeching 
any other part would have had the same effect ; as, 
in fact, by some persons blood is taken from the 
feet to relieve affections of the head, in preference 
to taking it from this part. 

I have endeavoured to explain why in typhus 
we should avoid stimulants as much as possible, 
inasmuch as the nervous centres being in a diseased 
state of congestion or inflammation, neither they 
nor other organs have their power increased by 
them ; whereas, by indirect (the sedative) practice, 
as it is called, we relieve the organs, and give them 
an opportunity of recovering themselves. 

Leeching or venesection in typhus is by no 
means more indirect practice, considering the symp- 
toms, than in many cases of peripneumonia, or of 
synocha in the advanced stages. These three states 
of disease, side by side, present the same aspect, 
neither of them having the direct indications for 
bleeding, if, as such, strength of pulse and flushed 
hot skin be required to be present. A patient 
in typhus has the same proportion of blood in his 
system twenty-four or forty-eight hours after the 
attack, as if he had been seized by synocha or 
peripneumonia, in which no one would hesitate to 
bleed : and the prostration of strength in the three 
diseases is, in many instances, exactly similar. Every 
practitioner knows that patients in peripneumony 
have the dusky colour of skin, the weak rapid 


pulse, and lie supine like typhous patients : nay, 
more — when in this most dangerous state, they 
scarcely cough, from oppression and insensibility, 
and the cases may be easily mistaken by the inex- 
perienced for idiopathic fever ; yet who would think 
a patient too weak to be leeched or bled, however 
weak the pulse may be, when he is comatose from 
congested lungs, and in danger of suffocation ? 
Where is the difference in the physical strength of 
the patient ; or why may not an exactly similar set 
of symptoms be relieved in typhus by similar means ? 
Sometimes a patient in peripneumonia cannot at 
once be bled from the arm when much sunk, any 
more than in typhus, lest fatal syncope should 
ensue ; but by applying leeches, and drawing the 
blood gradually, the patient will be so far relieved 
that blood may subsequently be freely taken from 
the arm, to subdue that inflammation, which had 
been but slightly relieved by the leeches ; or with- 
out leeches, by skilful management, a little blood 
may at once be taken with a lancet. No man be- 
fore Rasori had the determination to try " contra- 
stimulants" (bleeding, antimony, &c.) in typhus ; 
and he cured his patients by these means. 

But it must be remembered that the disease has 
a certain number of days to run, like small-pox ; and 
therefore the patient must not be bled from day to 
day when symptoms continue severe : nature can 
only be lightened of a load to a certain extent, and 
so helped to totter through the weary journey with 
the assistance of medicines.* Patients may be bled 

* I may here give an example, which approaches closer than 
peripneumonia to what is called typhus. My clinical clerk told me 


with advantage in ague ; but men have been incon- 
siderate enough to attempt to stop the ague by 

one day that a patient had arrived much sunk in typhus : we went 
to the bed-side, and found that he had all that appearance ; dusky 
skin vrith. petechia, eyes dull, lying on the back, answers incoherent, 
the pulse small, soft — 120; the skin dry, but rather below the 
natural temperature ; the tongue dry and brown in the middle, 
with a margin of white fur. He did not cough ; but on applying 
the ear to the chest, there was ronchus sonorus, gravis, sibilans, 
and crepitans — thanks to Laennec for enabling us to discover 
the last symptom. The man had been ill nearly a fortnight : and 
how often have we seen patients plied with wine in such circum- 
stances, from the supposition that they were sinking from debility ! 
I pronounced the case to be synocha petechialis, " complicated" 
with the bronchitis of the epidemic (December 1831) in an aggra- 
vated state, with incipient peripneumonia. This was a case to shew 
students that the debility of febrile disorders is oppression from 
relative over-load of blood, and the severity of disease — that de- 
pletion will lighten both, and that at the end of a fortnight it is 
not too late to adopt antiphlogistic practice. I recollect one stu- 
dent asking me if the man could bear bleeding ? My answer was, 
" Do you think, if a scaffolding fell upon you, you could bear to 
have it lifted off ? " We bled the patient immediately to sixteen 
ounces, gave him a purgative draught of salts and senna, and 
ordered it to be followed up by one drachm of sulphate of mag- 
nesia, and one-eighth of a grain of tartar emetic in solution, every 
fourth hour. The next morning he was nearly free from delirium, 
and sat up in bed ; the bowels were still confined, and he had some 
cough (p. 175, 1. 2). The cathartic was repeated ; but by mid- day, 
the medicine not having operated, he relapsed into stupor, the skin 
having become hot, and the relieved (p. 104 and 116) pulse 84, and 
full: he was immediately bled again, had another purgative draught 
and a purgative enema, and the saline antimonial continued. The 
next day, after the free operation of the medicines, he was relieved 
and the skin softer, but he coughed more. As he had been very 
delirious in the night, and the sensoriuua was still slightly affected, 
he had ten leeches to the temples ; and from this time he quickly 

In another of these petechial cases of fever, " complicated" 


mere repetition of bleeding, the mischievous result 
of which may be easily imagined. In cases of 
simple typhus it is seldom necessary to bleed from 
the arm, but almost uniformly from the head, with 
leeches, using at the same time cold lotion, saline 
antimonials, and purgatives. But in typhus, com- 
plicated with inflammation of lungs or other vis- 
cera, bleeding from the arm has been followed by 
as marked benefit as when the fever was not of 
the typhous character. 

There are persons who urge strongly that 
bleeding should never be resorted to in any dis- 
ease. I feel certain, however, that there are cases 
in which it would be unjustifiable to lose a mo- 
ment ; such as inflammation of the head or chest, 
whether idiopathic or from metastasis, in which 

with pleuro-peripneumony, which had been treated exactly in the 
same way — bled and leeched, &c. freely at the commencement — 
the patient (a girl set. 15) became, on the fourteenth day of con- 
finement to bed, much oppressed (sunk), feeble, lying supine, 
delirium increased, skin dusky, pulse weak and frequent, rhon- 
chus crepitans. One of the students asked if I did not think 
she was sinking from debility, accelerated by the former loss of 
blood ? My answer was, " Put your ear to her chest, and then 
bleed her;" and that there might be no mistake, I stood by until 
seventeen ounces flowed : from which time her pulse rose, and 
she gradually recovered. It is only clinical experience that can 
teach how apparent debility may be relieved by bleeding, or how 
late in a disease it may be resorted to with the most gratifying 

I would now ask, had these cases been called (according to 
Cullen) synochus, and the latter stage considered to be typhus, 
and stimulants resorted to, as they would have been by those who 
employ them in typhus, and do not resort to auscultation, what 
would wine or brandy have done for these cases, which were cured 
by bleeding, purging, tartar emetic, &c. ? 




bleeding produces immediate relief : and even the 
short time necessary for the sedative influence of 
medicine to be induced, might give time for irre- 
mediable mischief to take place. It is necessary 
to know that the quickest substitute for venesec- 
tion is an emetic of ipecacuan. or antim. tartar. ; 
and it should never be forgotten, that a table- 
spoonful of mustard (which may be found in every 
house), mixed with a little water, is a quick and 
efficient emetic, though not so sedative as anti- 
mony, &c. ; but it does to begin with, to be fol- 
lowed by saline antimonials and other sedatives. 
And I freely acknowledge, that a practitioner who 
is skilful and decided in the use of sedatives can 
dispense with venesection much oftener than is 
the common custom. 

In the commencement of fever, the saline anti- 
monial mixture of tartar emetic and Epsom salts 
should be given every half hour, until nausea or 
vomiting be produced, and then every two or three 
hours in diminished doses, so as to keep up the 
sedative influence. 

After all this, it may be asked, how it happens 
that stimulants sometimes save the life of patients 
in typhus ? In the states hitherto considered, the 
heart was not deficient in perception of the pre- 
sence of the blood — it exerted what strength it had ; 
but from the violence or long continuance of the 
fever it will sometimes flag, before the nervous 
system, upon which the vital powers depend, has 
made any progress towards amendment : the pa- 
tient will, in fact, begin to die, the pulse fluttering, 
with cold clamminess on the skin. It is now that 


artificial stimulus will sometimes renew enough of 
action to gain time for the nervous system to recover, 
if not already too far exhausted, or the respiratory 
function too far gone to arterialise the blood, in 
which case life cannot be sustained ; as may have 
been seen when the pulse has actually been kept 
up unavailingly by stimulants for many hours be- 
fore death. The point at which stimulants may be 
administered with benefit is one of the utmost con- 
sequence in practice, involves great responsibility, 
and can only be ascertained by experience at the 

Those who stimulate too early, by making the 
heart over-exert itself, and by expending the nervous 
influence, actually bring it and the nervous system 
sooner to that state described, in which a continua- 
tion of stimulus will be necessary to carry the patient 
through ; for upon every remission of the stimulus, 
they find the patient drooping ; and therefore, 
from observing this phenomenon, they become per- 
suaded that they have been pursuing the right plan 
from the beginning. I have shewn that sometimes 
there is a necessity for stimulants at the last, when 
the fever is gone (p. 158), which has been called the 
crisis ( f f the diathesis of disease being changed"), 
and yet not enough of natural strength left to carry 
on life. But how is it to be known when fever is 
gone ? By referring to its essence, the loss of function 
of the nervous system. The fever is gone when the 
nervous system begins to regenerate nervous influ- 
ence ; when the intellect becomes clear, and volition 
free, however weak — for subsidizes may still remain, 
and other marks of great debility, and there may be 


debility of brain, amounting to childishness, but deli- 
rium is gone, and the eye follows objects,* besides 
the evidence of renewed secretion in the mouth, 
nose, skin, &c. &c. Patients themselves can often 
refer to the exact time of the fever passing off, by 
the mere return of consciousness, although they 
may not have had power of moving or speaking ;f 
but even then we may have some difficulty in con- 
ducting them to perfect health, by food, tonics, 

* This is the great distinction, the eye ; for even in this stage 
there may still be delirium : but after the crisis or change of 
diathesis, it is no longer the dull-eyed typhoid delirium, but the 
delirium (tremens) of inanition ; and it is at this point that the 
experienced practitioner uses stimulants and opium with masterly 
effect. Even in the commencement of inflammatory and febrile 
attacks, the man of experience will be on his guard against a state 
of delirium tremens, and will ascertain the habits of the patient, 
who may have been accustomed to live freely and luxuriously, 
though much within the bounds of what could be called intem- 
perance ; and, again, delicate persons of nervous temperament, 
especially females, who live abstemiously, easily fall into the de- 
lirium of inanition. 

f A friend of mine, commander of a ship, on the crisis of fever 
becoming suddenly conscious, though still apparently dying, and 
unable to move or speak, heard his men talking over the mode of 
sewing his body up in his hammock, to consign him to a watery 
grave with the greatest propriety and respect. A lady told me 
that, after having been " given over in a tw r enty-one-day fever," 
she became suddenly conscious in the middle of the night, but 
unable to move or speak. Her maid and a hired nurse were dis- 
cussing the hopeless state of the patient over a jug of porter. She 
managed somehow to make them understand her desire to have 
some of it ; upon which they consulted together, and coming to 
the decision that it could not make her worse than she was, gave 
her nearly a tumblerful. She immediately fell asleep ; and, 
awaking in the middle of the next day refreshed and strengthened 
(see p. 189, 1. 25), startled her servant by speaking to her in a 
distinct voice. 


narcotics, stimulants, and occasionally perhaps a 
recurrence to sedative evacuations, according to 
the changes which take place. The collapse pro- 
duces a state of inanition favourable for the action 
of stimulus : nevertheless, if capillary action, con- 
traction, do not recommence in the cineritious sub- 
stance of the nervous system, death must take 
place in spite of stimulus. 

Those who, on the contrary, relieve the system 
early by sedative (antiphlogistic) treatment, will 
diminish the duration of the violence of the fever ; 
but as in every fever a poison is introduced into 
the nervous system, from the effects of which, in 
every case, a certain time is required for its re- 
covery, the young practitioner must not be induced 
to think that, by any measures, fever can be " cut 
short " all at once, or that it can be more than 
checked. There are some cases recorded which 
apparently support the opinion that free bleeding, 
&c. can stop idiopathic fever at once : but I am 
more inclined to think those have been symptoma- 
tic fevers, depending on some intensely acute in- 
ternal inflammation ; or if idiopathic, of that rapid 
course which sometimes takes place during epi- 
demics — sometimes malignant, but not always so. 
Or it is possible that idiopathic fevers have been in 
some instances so completely checked as to have 
appeared cured ; as patients in chicken-pox or mild 
small-pox feel well and able to exert themselves 
after the fourth or fifth day, though the disease is 
not gone for many days afterwards. As a general 
rule, idiopathic fevers, as far as I can judge by 
experience, run a definite course, though we have 


not such accurate information with respect to the 
duration of synocha and typhus as we have con- 
cerning small-pox, measles, and other febrile dis- 
eases produced evidently by infection, which also 
may be subdued, though not stopped, and of 
whose existence the spots are evidence, even when 
completely subdued ; as cases of mild small-pox 
frequently occur, as above alluded to, in which, if 
it were not for the danger of infecting others, the 
patient could attend to his business long before the 
crusts have fallen off; still, in those cases we know 
that there remains a spark, a smouldering fire, 
which is capable, during a short period, of being 
relighted. In many cases of fever also, the symptoms 
relax a week or a fortnight earlier than in others ; 
and, on the other hand, severe typhus or synocha, 
like small-pox, may be protracted much beyond 
the ordinary duration, even when not eventually 
fatal. Thus, the ordinary duration of fever is 
about fourteen days ; but when it is protracted to 
three weeks, the popular term applied to it is " a 
twenty-one-day fever," implying that it has been 
unusually severe. 

It may appear as if, having said so much against 
the misuse of stimulants, I were inclined to deny 
their utility, in fever ; but, on the contrary, I have 
shewn one state in which they become indispensable ; 
and that they are often of great benefit the moment 
the fever has ceased, when the influence of the 
poison has passed ofT, which has been called the 
crisis : there is then often so much real debility, 
that the patient's recovery (convalescence) would 


be very tedious, or perhaps the powers of digestion, 
&c. not equal to restoration, unless assisted by 
stimulus ; and when fever is gone, to promote 
appetite and digestion, wine may be of the most 
marked benefit, if not indispensable (pp. 179 and 
180, note). 

I have often been asked for a rule as to the ad- 
ministration of wine in fever, by persons who have 
remarked that they have seen others administer it 
with great success, but could not themselves feel 
certain in the indication. Besides what I have 
stated above, I would say, that the person who 
best understands the nature of delirium tremens 
will be the quickest to discern the propriety and 
necessity for the administration of wine and opiates 
in fever, erysipelas, &c. 

I may here observe, that narcotics are frequently 
useful during fever — nay, necessary — as may be 
understood by referring to the essence of fever, 
and knowing that sleep is nature's restorer of the 
deficient nervous influence. The obstinate wake- 
fulness which takes place in some cases of fever 
must have a deleterious tendency to produce col- 
lapse ; hence the benefit of gentle opiates :* and in 
support of this opinion and practice, I may quote 
two good recent authorities, Dr. R. Williams, in his 
useful and interesting work the Elements of Medi- 
cine, and Dr. P. M. Latham ; the opinions of both 

* From the congested state of the nervous centres in fever, 
syrup of poppies, or a few drops of laudanum, will produce an 
effect equal - to that of a larger dose of opiate medicine in other 
states of disease. 


having the value of being formed on extensive cli- 
nical experience. 

The eruptive fevers (exanthemata) are to be 
treated precisely on the principles already laid 
down. I cannot too seriously caution the young 
practitioner against implicit reliance on the noso- 
logists, as the exceptions to their rules are endless. 
For instance, scarlatina is put down amongst the 
exanthemata as occurring once only in life. I have 
known it occur three times in the same individual 
— frequently twice ; in one instance, in its exqui- 
sitely marked form, as to inflamed tonsils, appear- 
ance of tongue, eruption, and desquamation of skin, 
twice within ten months. It is said that the erup- 
tion appears on the third or fourth day. I have 
seen a child in good spirits, and perfectly well in 
every respect (having examined it on account of 
the other children in the family being affected with 
scarlatina), one evening, and before the next as red 
as a boiled lobster from the rash of scarlatina, 
with sore throat and swelled tonsils. An eighth of 
a grain of antim. tartariz. produced vomiting, with 
relief of the difficulty of deglutition, and stopped 
the swelling of the tonsils, within an hour. At this 
time the tongue was, as represented in the plate to 
Bateman's edition of Willan, with a white fur, and 
scarlet papulae staring through it. The following 
evening, a state of collapse came on, delirium, the 
pulse rapid and weak, the breathing laborious, lips 
purplish, skin cool, and rash faded. It is in simi- 
larly rapid cases that death takes place on the third 
or fourth day. I administered another dose of 


the tartar emetic, which produced vomiting in a 
quarter of an hour. Within two hours the breath- 
ing was relieved, the pulse fuller, though still 130, 
and the skin returned to its redness and full heat of 
regular scarlatina. The lips also lost their lividity, 
shewing the relief of internal congestion by the an- 
timony ; yet, in similar cases, how often have I seen 
wine, and even brandy, given to children of the 
same age (five years), who did not recover. On 
the third evening, less than seventy hours from the 
commencement, the child asked for animal food ; 
from which I felt certain that the crust must be 
coming off the tongue : and on inspecting it, found, 
in fact, that it was loosening at the edges ; and it 
began to come off in flakes during the night, and 
from the tonsils, which had never swelled any more 
after the first emetic. Thus the disease, which 
we usually see occupy seven or eight days, went 
through its phases within seventy hours. The 
child was well, and walking about the house, on 
the fifth day, the skin having desquamated. This 
patient, being a relative, and living near me, was 
visited, whilst dangerously ill, six times at least 
every twenty-four hours. I then prescribed sul- 
phate of quinine and sulphate of magnesia in 
water acidulated with sulphuric acid, about every 
six hours, and lemonade in abundance as drink ; 
the child had one dose of pil. hydrarg., and pil. 
aloes cum myrrha, the first day. The imme- 
diate relief of symptoms may be fairly attributed 
to the treatment, though not the rapid progress 
(evinced by the early desquamation), of the disease ; 
for, on the contrary, it shewed a rapidity of malig- 


nity in itself, as we too often see in fatal cases. 
Quinine has not much influence on any continued 
fever ; but it unquestionably makes the convales- 
cence more rapid in all cases. I esteem the sulphuric 
acid, and the lemonade drink, or lemonade made 
with lemon-peel and the mineral acid, of the great- 
est use as a lotion to the fauces and primae viae,* 
which are in an inflamed or congested state : in the 
case above related, they assisted in preventing the 
croupy state which sometimes destroys life in scar- 
latina, a copious coriaceous lymph in the fauces 
having existed when the laborious breathing came 

I may observe, that small-pox differs from the 
other eruptive fevers in one respect as to its nature, 
which does not alter the indications of cure, but only 
increases its difficulty. Small-pox is dangerous in 
proportion to the quantity of eruption ; whereas the 
others are rather the reverse. (I do not include 
chicken-pox, in which there is no danger.) Inde- 
pendently of the fever, small-pox destroys life, when 
there is a great amount of confluent eruption, by 
the depression of the system, produced through the 
destruction of a large surface of the skin, such as 
takes place from extensive burns or scalds, which 

* The nitro-muriatic and other acids have been recommended, 
by many experienced practitioners, in fevers, as well as for gargles ; 
and I may observe, that their utility, when applied to the mucous 
membrane within view, as in the fauces, will explain the efficacy 
of the vegetable or mineral lemonades in relieving the tenesmus, 
griping, nausea, &c. of bilious diarrhoea, more quickly in the first 
instance than opiates alone ; as they not merely constringe and 
relieve the congested or inflamed capillaries of the mucous mem- 
brane, but help to wash away the acrid bile. 


are confessedly very fatal. The large number of 
terminal branches of nerves destroyed in these 
cases fully accounts for the degree in which the 
constitution suffers. 

It will be useful to point out in this place the 
distinction between disease in an organ arising se- 
condarily during fever, and primary disease of the 
same organ exciting fever. Our subject will be 
equally illustrated whether we select an organ in 
the chest or abdomen. Let us take a case of 
idiopathic continued fever, in which, from the dis- 
turbance in the secreting organs, gastric morbid 
sensibility comes on early ; the mucous membrane 
of the intestines being irritated by their unnatural 
contents, there is uneasiness of the abdomen on 
pressure, and great heat and dryness of the epigas- 
trium, without either diarrhoea or any obstinate 
constipation ; and along with this, languor, pro- 
stration of strength, more or less confusion of ideas, 
or delirium, evincing lesion of the nervous system, 
the essential marks of fever. 

On the other hand, let us take a case in which, 
from any cause, there is a deficiency of good bile 
in the intestines ; the food, instead of being digested 
in the natural way formerly described, becomes 
putrid, acid, or otherwise acrimonious, not afford- 
ing nourishment, and at the same time irritating 
and producing morbid sensibility. We shall here 
have the same gastric symptoms ; but instead of 
fever, there will be only feverishness (pyrexia), from 
the disturbance (morbid sensibility) communicated 
to the nervous system, inducing heat of skin, quick 



pulse, &c. (pp. Ill, 117, 121); headache perhaps, 
but not delirium ; and little languor, until actual 
debility from inanition ensues. 

Now, as to treatment, if tartar emetic be given 
in the dose of about one-eighth or one-fourth of a 
grain in water every hour, the effect upon the case, 
depending upon mere gastric morbid sensibility, 
will be to produce sickness, by which the patient 
will be relieved, and immediately cooled, particu- 
larly if the bowels be opened by it at the same 
time ; and a repetition of the tartar emetic will 
produce sickness each time. 

But the effect of tartar emetic on the case of 
fever will be less marked ; for though it may pro- 
duce nausea at first, with some diminution of febrile 
symptoms, yet the relief is not so decided ; and if 
the medicine be repeated, it does not produce 
nausea, but only diminishes the febrile symptoms, 
and requires to be persevered in to continue the 
control over the fever, or may even require in- 
creased doses, and to be assisted by bleeding. This 
latter case exemplifies what in the new Italian doc- 
trine is meant by a strong diathesis, in which there 
is great tolerance of contra-stimulant medicines. 

Now, either case of disease may prove fatal : 
the idiopathic fever by the gradual failure of the 
functions of the lungs, heart, and brain ; the sym- 
pathetic fever from gastric disease, by rapid maras- 
mus ; for though the sedative tartar emetic cools 
the patient, and subdues the symptomatic fever for 
the moment, if digestion cannot be restored, the 
patient will rapidly sink under renewed symptom- 
atic fever and inanition ; and the same result takes 


place whether the disease be gastro-enteritis (that 
is, inflammation), or gastro-enteric morbid sensi- 
bility, caused by the irritation of undigested aliment 
from want of secretion of good bile. The latter 
case is an illustration of what takes place in 
infantile fever (the infantile remittent), or gastric 
fever of children. It is often cured in the com- 
mencement by a dose of calomel, either alone or 
with castor oil or other purgatives, evacuating the 
primae vise ; whilst at the same time the mercurial 
renews the secretion of bile, so as to restore diges- 
tion, and all goes on well, either permanently, or 
only requiring a repetition of the same remedies. 
But often the case is more obstinate, and a torpid, 
congested, or perhaps we should say sub-acutely 
inflamed state of the liver, requires not merely re- 
peated doses of calomel or other mercurials, but 
leeches and poultices, or cold* wet cloths, to the 
epigastrium. One of the embarrassing symptoms 
in these cases is a purging of a dirty watery fluid ; 
but this must not dissuade the inexperienced from 
persevering with calomel ; for as soon as it makes 
the motionsf yellow or green, this state will cease ; 

* The application of cold is, I think, not sufficiently often used 
in inflammation of the viscera of the chest and abdomen when the 
surface becomes decidedly hot. 

f The appearances of the faeculent excretions, though con- 
stantly examined, are not, I believe, sufficiently understood. The 
first thing with which the student should become acquainted, with 
respect to the appearances of the intestinal excretions, is the 
variation of the natural colour, which resembles that of gamboge : 
this substance, when moistened, is of a pale bright yellow, and, 
when dried, gradually becomes darker until quite dark brown. 
Such are likewise the shades of tint of the faeces in health ; be- 


or if chronic diarrhoea then continue, as it some- 
times does, from a chronic inflammation or con- 
gestion of the mucous membrane having been in- 
duced, astringents, such as catechu or hsematoxy- 
lum,* will cure it. These cases, though called 

coming paler in proportion to the scantiness of good bile, until, 
when that is wanting altogether, they assume a light grey appear- 
ance. When, for example, the liver is inflamed, gorged, and 
swollen, it excretes a quantity of nearly black bile, causing diar- 
rhoea, as is frequently seen in the hepatic complications of fever 
in hot climates : calomel, sulphate of copper, and liquor arseni- 
calis, are remedies for this black bile. In the chronic hepatitis of 
persons of intemperate habits there is often an abundant secre- 
tion of a reddish bile. There are some substances, more especially 
calomel, which produce a chemical change in its colour, and con- 
sequently in the colour of the motion, rendering it grass-green ; 
and persons who are ignorant of this fact often continue to give 
more mercurial and other medicines, though the green colour of 
the faeces is a proof that sufficient secretion from the liver is 
going on, the colour being that of good bile acted upon by the 
medicine, shewing therefore that more is unnecessary. Foul, 
slimy, mucous, or gelatinous matter in the faeces is an evidence 
of over-purging from diarrhoea, dysentery, cathartic or other medi- 
cines, &c, and generally indicates the propriety of astringents 
and mucilaginous diluents. 

The alterations of the secretion of the kidneys have been 
already alluded to, and the peculiarities in each disease are gene- 
rally understood. Young practitioners and patients are frequently 
unnecessarily anxious about the common appearance of precipita- 
tion of faeculent sediment, sometimes with a reddish tinge, which 
takes place as the natural process of the decomposition of the 
urine after standing a few hours, and which varies very much 
within the limits of healthy secretion, according to changes of diet, 
wine, &c. 

* Medicines and dietetic directions sometimes fail merely from 
being too energetic. Thus, a child aged eight was very pale and 
wasting, with no evidence of disease except total loss of appetite, 
which had ensued after mild scarlatina. She had slight swelling 


infantile remittent, unlike the genuine aguish re- 
mittents, are little relieved by bark. 

Notwithstanding that we have made out clearly 
enough that there is a synocha and a typhous fever 

of the submaxillary gland, but could not be called strumous. A 
medical friend, who saw her, prescribed animal food and fermented 
liquor, compound infusion of gentian with a little quinine, and 
gentle laxative doses of calomel and rhubarb, as the bowels did 
not act. Finding in a week that she was no better, and annoyed 
with flatulence and acidity in addition, he consulted me. 

The prescription was excellent, could it have been borne ; but 
as excessive debility of the mucous membrane and glands of the 
prima? via? existed, a milder medicine and diet were indicated. I 
prescribed half an ounce of decoction of hsematoxylum, with an 
equal quantity of chalk mixture, to counteract the acidity and 
flatulence, and half a drachm of Epsom salts, to keep up the peri- 
staltic action, three times in the twenty-four hours ; and a diet of 
animal food made into a strong soup, instead of giving it hi sub- 
stance, with milk and bread. In ten days this plan induced 
appetite and digestion, and enabled her to resume the medicine 
and diet at first prescribed, which soon perfected her cure. 

The logwood, from its slightly sensible qualities, is much 
undervalued as a mild tonic, and is too much looked upon as 
a mere astringent, though it contains little tannin. It is so 
commonly considered as a mere astringent (on account of its 
great efficacy in checking diarrhoea and dysentery), that the pre- 
scribing it with a saline laxative would be thought contradictory 
by those who do not consider that it was given in the above case 
as a mild and efficacious tonic. Some think it contradictory to 
give an astringent . with an aperient, because astringents have 
been usually exhibited along with stimulants and stimulant nar- 
cotics — in diarrhoea, for instance ; but enough has been already 
said to shew the benefit of astringents with salines where the 
diarrhoea is combined with an inflammatory congested state of the 
mucous membrane and a febrile state at the same time ; and that 
simple narcotics and astringents in themselves are not " heating," 
any more than tonics : though the patient will become heated 
if the requisite collateral treatment be neglected (p. 92 et seq.). 



— i. e. fevers which begin, continue, and terminate 
with the characters given of those diseases ; and 
that in those cases called typhus there is the 
strongly marked difference of sensorial oppression 
—the question arises, whether these states are 
really specific, or only accidental differences ; and 
whether there be really a specific typhus or not ? 
— in other words, whether there be any simple con- 
tinued fever but the one which, arising from the 
same infection, or other exciting cause, may assume 
the garb or type of synocha or of typhus. The cir- 
cumstance of Cullen having made a synochus fever, 
shewed that he could not establish a diagnosis, and 
therefore produced a hybrid. The synocha pete- 
chialis, for instance, is constantly called typhus, 
when seen for the first time in the sunken state 
above described, or it is named synochus by those 
who have observed that the fever was not typhous 
at the commencement, but did not at the same 
time notice the petechial eruption. In the assertion 
that its nature has been frequently undetected, I 
am borne out by the opinion of that accurate and 
talented physician Dr. R. Bright. 

We have some analogies in the well-defined 
exanthemata, which would make us doubt the ex- 
istence of a specific typhus ; for instance, the erup- 
tive fevers in their ordinary routine correspond 
with the synocha of Cullen, with strong pulse, 
&c. ; but it is well known, that where scarlatina 
attacks several members of a family, some of them 
will have a typhous fever from the beginning, with 
scarcely any rash. Measles may present the same 
phenomena. The spots of synocha petechials fre- 


quently do not appear till about the ninth day. 
Should the disease have taken a typhous turn before 
that time, the spots may have never been seen, or, if 
discovered, were faint, so as not to be distinguished 
from the typhous petechias (which are little ecchy- 
moses, not rash,) with which they were mixed. 
When called in to cases of this disease, I have fre- 
quently asked whether the patient had any eruption, 
and been answered decidedly in the negative ; but 
upon examining the chest, especially towards the 
axilla, have pointed out numerous spots of the 
rash, which had not been observed by the attend- 
ants. It has been remarked by experienced practi- 
tioners, that when typhus has been prevalent, some 
cases (which they nevertheless still called typhus) 
have occurred in which the sensorium was not 
much oppressed — some with a strong pulse at the 
commencement, some with hot skin, &c. &c. ; in 
fact, that " no one symptom could be found uni- 
formly present." This goes to confirm my opinion, 
that there is but one simple fever, and which is exan~ 
thematous, petechial, though the rash may never be 
sensibly developed, as in scarlatina maligna ; that it 
is continued, synochous (" synocha," evvi%ea) t whether 
with high or low pulse, high or low temperature ; 
and that, when the sensorium is oppressed in addition 
(p. 154, note), it is typhous (typhus). 

Having taken a view of the train of symptoms 
denominated fevers, symptomatic and idiopathic — 
which we have traced to a loss of the functions of 
the nervous centres, and subsequently of the organs 
depending on them, — we next have to consider 



other diseased states, denominated neuroses, which, 
like fevers, consist primarily of derangement of the 
nervous system, though differing from them in the 
subsequent phenomena; and the leading charac- 
teristics of which are pain, and a tendency to 
spasmodic, convulsive, involuntary motion. It is 
necessary to keep distinct views of these different 
states of diseases (febres and neuroses), though 
they sometimes run into each other ; pyrexia (fever- 
ishness) participating somewhat in the characters 
of each. 

In explaining these disorders of the nervous 
system, neuroses, we must still refer to the prin- 
ciple of disease being only the alteration of healthy 
actions. Hence a sound physiology is absolutely 
necessary as a substratum to the practice of medi- 
cine ; for, however much has been gained in patho- 
logy in general by mere experience, the practi- 
tioner will observe, as he advances in acquaintance 
with the neuroses, how completely we are depend- 
ent upon a knowledge of the manner in which the 
functions of the nervous system are carried on in 
health, for any correct principles which must guide 
us in their treatment. 

When the sensibility of a part morbidly increased 
becomes pain, and this takes place without per- 
ceptible accompanying inflammation, pathologists 
name it a state of neuralgia, implying merely pain 
of nerve, in contradistinction to pain from inflam- 
mation, in which there is always palpable evidence 
of the vessels being implicated. Neuralgia has been 
known by the term " irritation," or "irritable state 
of a part," as the " irritable spinal cord," " irritable 


mamma, uterus," &c. This morbid sensibility is in 
the nerves, existing often without that participation 
of the vascular tissues which constitutes inflam- 
mation, though sometimes inflammation is induced 
by it. 

Now, when this state, which I call morbid sen- 
sibility, of sensitive nerves exists, it is indicated by 
pain. But it may exist in the organic (and inci- 
dent ?) nerves without pain ; and thus the disor- 
dered state be set up in the nervous centres, pro- 
ducing evident symptoms, by spreading thither 
from a part in pain, or from a part not in pain, 
according to whichever class of nerves is injured. 

The import of the term morbid sensibility must 
not be misunderstood, because I apply it to a state 
of the central organ, of which the patient's senso- 
rium is not conscious : he does not then feel the 
morbid sensibility ; but the central organ, the spi- 
nal cord, does feel, as it were — it is over-susceptible 
to impressions on its nerves : therefore the state is 
morbid susceptibility, excitability, or sensibility of 
the spinal marrow, independent of animal sensation 
(p. 118). 

An inquiry into the nature of the proximate 
cause of morbid sensibility ("irritation"), or the 
actual state of the minute filaments composing the 
nerves and central masses of medullary matter 
when they evince the phenomena of morbid sensi- 
bility, offers an extensive field for research. Is it 
inflammation ? It has occurred to me that it will 
hereafter be proved, perhaps, by means of the mi- 
croscope, that it is inflammation of them, neuritis 
(p. 45), either in the tract of the nerves, or at their 



union with the nervous centres. It is necessary 
to observe, however, that as in external parts, so 
also in the nervous centres, morbid sensibility, with 
or without pain, exists with a state short of in- 
flammation, viz. with that state of inanition or 
contraction of capillaries which we sometimes see 
to precede inflammation, but which is not always 
followed by inflammation (p. 70, 1. 17; p. 136, 
1. 22; p. 143), as in case of haemorrhage, sudden 
fright, excessive cold, or an excessive quantity of 
digitalis ; the whole of which produce the convul- 
sions of morbid sensibility, and all evidently induce 
the contracted state of capillaries, the opposite of 
inflammation. Some of the symptoms of general 
morbid sensibility result from the inflammation 
which ensues upon excessive contraction : the two 
opposite states of contraction and dilatation of 
capillaries, therefore, are accompanied by the same 
phenomenon, morbid sensibility ("irritation"). An 
exemplification is the morbid sensibility which ac- 
companies symptomatic (" irritative ") fever. In 
order, therefore, to cure, we ought to know whe- 
ther the indication be to employ stimulants to 
dilate the capillaries, or sedatives and tonics to 
constringe them. 

The consequence of the brain or spinal cord 
becoming in a state of morbid sensibility is, that 
its healthy actions are deranged : that is to say, 
in health the brain communicates to the muscles 
of voluntary motion the dictates of the will only ; 
but if the origin of the voluntary nerves of a part, 
in the brain, be in a state of morbid sensibility, or 
if the same disordered condition of the part of the 


medulla spinalis through which the nerves pass 
exists, that part may be thrown into action inde- 
pendent of the will, or even against its dictates. This 
is the explanation of those involuntary motions, con- 
vulsive or spasmodic, arising from a spicula of bone 
within the skull, or a tumour pressing on the brain, 
which produces convulsions called epileptic ; or a 
depressed fracture of the skull, which also causes 
convulsions. Similar local . injuries of the spinal 
cord are followed by the like results. The same 
effect is even produced when nerves, being injured 
at a distance from the nervous centre, the injury, 
whatever it may be, whether physical (neuritis ?), 
or an alteration of the dynamic or electroid pro- 
perty of the nerve, spreads, whether of sentient or 
of organic (or incident ?) filaments ; so that the 
injury of the nervous centre at the origin of the 
nerves of motion makes it re-act and throw the 
muscles of voluntary motion into involuntary ac- 
tion, which is the rationale of locked jaw, tetanus, 
hysteria, some kinds of epilepsy, &c* It is well 
known to those who have seen much surgical prac- 
tice, that epileptic convulsions, as well as tetanus, 

* The morbid sensibility from long- continued voluntary action 
of the sphincters induces reaction in the form of the convulsive 
motions called rigors, or shivering. Every nurse knows, when 
she feels an infant shiver, that it is about to make water ; and the 
shudder produced by the sphincter vagina? is well known, as also 
the shivering produced by the painfully continued action of the 
sphincter ani caused by piles, or by the necessity of retaining the 
faeces against the natural inclination. These instances of shiver- 
ing are convulsions independent of temperature. We see an 
almost involuntary reaction when a person under the influence of 
pain clenches the hands or grinds the teeth. 


will come on occasionally from morbid sensibility 
in the nerves of a fractured or wounded limb. 

Mental excitement, such as anger, grief, fear, 
&c, which are analogous to the direct irritation of 
the brain or spinal cord by a depressed fracture or 
spicula of bone, will produce the state of morbid 
sensibility of the nervous centres indicated by in- 
voluntary, or almost involuntary, muscular actions 
— even by epileptic fits. Laughing and sobbing 
(convulsions) are produced by the cerebral excite- 
ment of good acting, and of various kinds of elo- 
quence. Again, we know that a person may be 
tickled into fits ; that certain pleasurable sensations 
in excess may produce epilepsy ; which is analo- 
gous to the accidental injury of nerves at a dis- 
tance from the central organ. The instances of 
morbid muscular actions produced through im- 
pressions on the brain shew that, notwithstanding 
the independence of the spinal cord as to some of 
the functions or properties of the nervous system, 
a most intimate connexion exists between them, 
although the mode of connexion has not been 
hitherto satisfactorily explained. 

Impressions upon the nervous system, distinct 
from the brain — for instance, any continued irri- 
tation of an organ, as of worms in the intestinal 
canal, though scarcely or not at all perceived by 
the individual, or disease of the nervous centres 
even in the foetal state — will produce partial or 
general convulsions, or a permanent spasm of cer- 
tain muscles, as of the gastrocnemii, &c, giving 
rise to the production of club-foot, as shewn by 
Dr. Little in his treatise on the cure of that dis- 


ease by division of the tendo Achillis or other ten- 

Or a higher degree of injury at the root of the 
nerve may produce paralysis, which, by destroying 
the equilibrium of the different classes of muscles, 
is another cause of club-foot and other contrac- 
tions of limbs. The well-known fact of diarrhoea 
producing cramps in the calves of the legs, is an 
additional illustration of this subject. These par- 
tial and general convulsions, or spasms, arising 

* There have been at all periods attempts made to cure con- 
tractions of the joints by mechanical apparatus alone, without 
cutting the tendons of the contracted muscles ; and the success 
in some has made instrument- makers and others, who do not 
understand physiology and pathology, think that all cases are 
curable by this means. Dr. Stromeyer and Dr. Little, both in 
their publications and practice, prove that many cases are curable 
by apparatus, without dividing tendons. Dr. Little has farther 
shewn, that there are certain cases in which even instruments are 
not required ; but that, being spasmodic affections, they are cura- 
ble by medicine alone, combined sometimes with a little manipula- 
tion. He has also clearly pointed out the cases in which the ten- 
dons must be divided ; thereby setting aside the absurd assertions 
which have been made, through want of sufficient experience in 
the actual treatment of these diseases, or through not having suf- 
ficiently considered the subject. Granting that there is a certain 
class of cases which might, with great care and attention, be cured 
by instruments in the course of from one to six or seven years : 
by adding the operation, which is scarcely painful, and not in the 
least dangerous, these cases may be remedied in as many weeks 
— sometimes, it might almost be said, in as many days ; for in 
many instances, as the minute wound invariably heals by the first 
intention, the patient begins to put the foot to the ground in a 
day or two ; so that, independent of there being cases not curable 
by instruments alone, the cases curable by them are remedied by 
the Stromeyerian plan without any comparison of time, expense, 
or pain, or, according to the old adage, tuto, cito, et jucunde. 



from irritations at a distance from the nervous 
centre, are instances of morbid reaction (deranged 
" reflex " actions) of the spinal marrow ; and the 
tenderness (morbid sensibility) of the abdomen in 
hysteria, without inflammation, is an example of the 
morbid sensibility of the spinal cord (induced by neu- 
ritis?) propagated from the uterus (p. 120, et seq.). 
To compare small with great things, there is an 
analogy between globus hystericus and hydropho- 
bia ; and the discovery of a cure for the latter, in 
some medicine which has a rapid effect in allaying 
that state of the nervous system common to the 
neuroses, and which I have ventured to designate 
neuritis, should not be despaired of. In fine, we 
see that convulsions, — involuntary actions or spasm 
of the voluntary muscles, as well as spasm of the 
involuntary muscles, — are produced by whatever 
excessively excites (produces morbid sensibility of) 
the nervous centres, either locally or from a dis- 

In neuralgia there is no perceptible alteration 
of structure, as in painful chronic affections of the 
face, heart, stomach, uterus, mamma, colon, &c. ; 
whereas many serious and destructive inflamma- 
tions, combined with pyrexia, give but little pain. 
The degree of constitutional or general morbid sen- 
sibility is also not proportioned to the local pain, or 
inflammation, but often much greater; nor has it 
been hitherto explained why one gun-shot wound 
of a limb should produce fever, and an apparently 
exactly similar one locked jaw. The difference, 
however, I am inclined to believe, depends upon 
whether the cineritious or the medullary part be 


principally affected : fever consisting of congestion 
of the former — tetanus, of disturbed action in the 
latter — the state of morbid sensibility (neuritis ?). 
Fever and general morbid sensibility must be well 
distinguished; for though fever be accompanied by 
morbid sensibility, as nausea, headache, rigors, &c. ; 
and continued severe constitutional morbid sensi- 
bility may be accompanied by febrile excitement of 
skin and pulse, we must be cautious in depleting in 
the neuroses, as depletion increases the sensibility of 
the nervous system ; and this, in some of the neu- 
roses, is a difficult point to discriminate in practice, 
when an organ of importance appears to be impli- 
cated, as when hysteria simulates peritonitis, peri- 
carditis, pleuritis, or phrenitis. We must not, how- 
ever, underrate the consequence of morbid sen- 
sibility, though it be not fever, for it sometimes 
proves fatal, as in tetanus, hydrophobia, &c. We 
may consider gout of the stomach to be a mixed 
case, and it is relieved by treatment different from 
what we should resort to in inflammation of that 
organ with fever, in which we should employ de- 
pletion and antiphlogistic means ; for in gout in the 
stomach* we must immediately resort to laudanum/)* 

* Gout commences with neuralgia, inflammation follows : 
the painful morbid sensibility may stop the action of the heart, 
through the nerves of the solar plexus, and cause death before 
there is time for inflammation, — like a blow on the pit of the 
stomach, or the swallowing an inordinate quantity of ardent 

f Laudanum will be enough, if the heart has not begun to 
flag. A young practitioner nearly lost a gouty patient by treat- 
ing him for gastro-enteritic inflammation with leeches, &c. ; when 
a clinical clerk of mine, who happened to call in, recognised gout 


and sometimes, if the pulse flags, to brandy, for the 
relief of the morbid sensibility. Again ; another in- 
stance of morbid sensibility — without fever, though 
sometimes with considerable pyrexial flush of sur- 
face — occurs sometimes after parturition, where, in 
many cases, an inexperienced person would sup- 
pose, from the tenderness on pressure of the abdo- 
men, that there was puerperal peritonitis and a 
necessity for bleeding ; whereas all that is requisite 
is an opiate and repose. Bleeding or purging would 
be highly injurious, the tenderness being only mor- 
bid sensibility of the part, arising from the origin of 
its nerves being rendered morbidly sensible by those 
of the uterus. 

In many instances where there is inflammation, 
if there be also much morbid sensibility, evinced 
by pain, the latter is a most urgent and dangerous 
symptom ; as in cases of poisoning by oxalic acid, 
cantharides, and other acrid substances (p. 60, note), 
in which, besides getting rid as much as possible of 
the poison, large doses of opiates are necessary. 
Remedies which are of use in inflammation with 
fever are of little avail, if not injurious, in the im- 
mediate treatment of cases wherein morbid sensi- 
bility is the predominant symptom, as in the case 
just alluded to, or in gout in the stomach. 

There is great difference between fevers and 
neuroses, both in proximate cause and treatment. 
In fever there is, in my opinion, lesion of the cine- 
ritious part of the nervous system chiefly, render- 

in the stomach, and speedily set him to rights by a large dose 
of laudanum. 


ing it insusceptible of being beneficially affected by 
ordinary stimuli, as above explained, the delirium 
or coma of fever being that of plethora or oppres- 
sion. In the neuroses the nervous system is sub- 
jected to some noxious local influence or impres- 
sion, which produces altered sensibility or spasms 
of various recurrence and duration ; as seen in a 
healthy animal convulsed from loss of blood ; con- 
vulsions in a healthy child from teething, worms, 
&c. ; tetanus produced by cold ; hysteria, chorea, 

Most or all of these forms of neuroses — vari- 
ously modified indications of the state which, in 
opposition to fever, I call morbid sensibility (" irrita- 
tion") — appear to depend more particularly upon 
diseased action of the medullary parts of the cen- 
tral organs, however produced, whether arising 
there primarily, or induced there by disturbance 
in the periphery of the organs. The delirium or 
coma of inanition — delirium tremens, delirium from 
loss of blood — depends upon a state of the cineri- 
tious tissue the* reverse of fever, anaemia rather 
than plethora. But although, upon a careful ana- 
lysis of the symptoms and the different forms of 
the neuroses, we may, with attention to physio- 
logy, refer some to an affection of the cineritious 
(in which I include the cineritious parts of the 
cerebrum and cerebellum, the grey matter of the 
spinal cord, and of the sympathetic system), others 
of the medullary parts of the nervous system, we 
should, a priori, from our knowledge of the con- 
nexion and mutual co-operation of these two divi- 



sions of the nervous system, expect to meet with 
disease depending upon simultaneous disturbance 
in both. Thus, from the violent operation of se- 
datives, or when an animal is bled to death, the 
first to suffer is the most vascular, the secreting 
and the sensorial part, the cineritious substance ; 
hence the indistinctness of the perceptions and 
thoughts, and the weakness of the involuntary and 
voluntary actions. If the operation of the sedative 
be increased, or the analogous injury of further loss 
of blood take place, the medullary part of the ner- 
vous system evinces its effect by general spasmodic 
muscular contractions. The state of the medullary 
matter during this time is represented by the symp- 
toms which I designate morbid sensibility, which 
may exist in all grades constituting the various 
forms of neuroses — from a slight neuralgic pain, to 
the most distressing clavus hystericus, tic doulou- 
reux, or agonising pain in the back of the head and 
loins, as in hysteria or from haemorrhage ; from the 
spasm of one or more muscles, the gastrocnemius 
or those of the jaw, to the universal spasm and 
universally increased sensibility of tetanus and hy- 
drophobia. Epileptic convulsions from terror must 
be a compound affection — the disturbance of the 
medullary part depending upon the previous affec- 
tion of the sensorial. The actual condition of the 
capillaries of the medullary tissue, — the proximate 
cause of the symptoms of morbid sensibility, i. e. 
whether the phenomena of the latter depend solely 
upon an alteration of the dynamic state of the ner- 
vous tissue, independently of any physical change 
in the capillaries, such as neuritis, for example, is 


a more difficult subject to determine. Whatever it 
be, it is a state relievable by narcotics and tonics 
with stimulants, and injured by sedatives, in oppo- 
sition to fever. 

Delirium tremens affords a good contrast to 
fever. This disease is analogous to the state (de- 
scribed p. 83) of a weakened action of the brain 
induced by forced watching. In delirium tremens 
the weakened action of the brain is produced by 
the absence of accustomed stimulants ; thus, in 
those who are in the habit of using much stimulus 
(of fermented liquors), the heart being accustomed 
to it, its actions proceed with regularity : when sud- 
denly deprived of it, either from accidental cause, 
from voluntary refraining, or from its being forbid- 
den on account of some disease or accident,* — the 
want of it causes the pulse to become weak, as if 
from the operation of digitalis, or other sedatives ; 

* Young practitioners in medicine or surgery are frequently at 
a loss to account for the state of a patient under such circumstan- 
ces, seeing that he is very ill without marked symptoms arising 
directly from the primary disease. Thus in the case of a gentle- 
man in the habit of living generously, rather high, though by no 
means intemperately, and whose brain had been during health in 
a state of constant activity, being moderately leeched and purged, 
with a very low diet, for common sore throat, on the third day he 
fell into delirium tremens, which required the copious and long- 
continued administration of opium, with brandy and water, to 
subdue it. In a similar manner the sudden change of diet neces- 
sary in surgical cases, often brings on delirium tremens in various 
degrees, both with the rich and the labouring classes, more espe- 
cially the latter, who, when intemperate, indulge more in ardent 
spirits. It is only of late years that this state has been thoroughly 
understood, and even now the gradations of the affection occa- 
sionally produce embarrassment. 




the absence of stimulus being equivalent to the in- 
fluence of sedatives. The brain at the same time 
is sound, and remains in full activity, but weak from 
the want of arterial injection, and of the usual sti- 
mulus. There is, therefore, a succession of thoughts, 
rapid but weak (delirium), wakefulness (pervigi- 
lium), and weakness of volition, causing trembling, 
whence the denomination " tremens."* Delirium 
tremens is a state analogous to that produced by 
sedatives, which if slight will pass off, but to which 
at last, if not relieved, succeeds the coma of inani- 
tion and death. The only mode of remedy is by 
narcotics and stimulants ; by which, in addition to 
the counteraction of the sedative state, a greater 
tendency to sleep is produced. The stimulant nar- 
cotic opium, or the simple narcotic morphia, should / 
be used — not the sedative narcotic hyoscyamus, 
which itself produces delirium tremens (p. 88). At 
the same time that the patient is using incessant 
muscular action (jactitation) and raving, the pulse 
is frightfully weak, as in persons dying of haemor- 
rhage : stimulants and opium must therefore be 
given freely until they counteract this state, and 
the patient must be confined to his room ; for if 

* I here give but the leading symptoms ; the detailed descrip- . 
tion will be found in the London Medical and Physical Journal, 
January, 1813, and in various works since that date. A clinical 
lecture by Dr. Roots, printed in No. I. of the St. Thomas's 
Hospital Reports, forms an excellent treatise on this subject ; and 
in one of his lectures reported in the London Medical and Surgical 
Journal, 1832, there is a clear exposition of the treatment of 
another form of morbid sensibility, viz. colic. In fact, every 
practical observation given by this estimable physician is worthy 
of attention. 


allowed to run about, as inclined to do, owing to 
the delirium, syncope will ensue, and probably ter- 
minate fatally. When the stimulants begin to pro- 
duce their good effect, we first perceive the brain 
recovering power, evinced by more steadiness of 
the ideas and rationality ; succeeded by calmness, 
then sleep ; and we cannot with safety relax stimu- 
lation until the patient does sleep, as the raving 
will otherwise return. Sometimes the patient will 
sink into sleep previously to becoming rational; 
but some degree of calm of the sensorium will 
usually be perceived first, and increased firmness 
of the nervous system, evinced by less trembling, 

Friends or attendants who do not understand 
the nature of the affection, and have been accus- 
tomed to consider that all delirium depends upon 
what has been called determination to the head, 
and that depletion is required, have resorted too 
often to bleeding, purgatives, and other sedative 
medicines, which increase the malady ; and they 
will even remonstrate with the physician sometimes 
against the exhibition of the only remedies which 
are efficacious. The bowels are usually torpid in 
delirium tremens, and will remain so until stimu- 
lants cause them to act, by restoring that state of the 
nervous system in which the nervous principle is 
developed and distributed to the alimentary tube 
as to other parts, besides their stimulant agency 
upon the muscles of the intestines themselves (vide 
p. 78) ; and hence the administration of the sedative 
cathartics is not merely useless, but, by counteract- 
ing the stimulants, rather retards than promotes the 



cure of the patient. The bowels in general act of 
themselves, therefore, as soon as the energy of the 
nervous system is restored by stimuli ; and when 
the urgent symptoms are removed, it is time enough 
to give laxatives, if then required. 

This is analogous to the constipation of bowels 
in tetanus. Has any one ever succeeded in purging 
a tetanic patient by the most drastic medicines, 
until the nervous system was relieved? or if patients 
do recover from tetanus, when purgatives, calomel, 
aloes, salts, &c. have been administered, may not 
the mischievous sedative effects of the latter have 
been neutralised by opium and stimulants taken at 
the same time ; or when we find tetanus being so 
often fatal, even when opium and stimulants have 
been resorted to, is it not probable that sometimes 
the quantity of sedative and drastic medicines has 
counteracted the effects of the former, which might 
have cured ? 

I think, from the various statements already 
made, it may be deduced, that the diseases of mor- 
bid sensibility, were it proved that they depend 
upon inflammation, are not curable by common 
depletion : the medullary tissue is too fine to be 
affected by the force of the circulation, or relieved 
by taking off the vis a tergo, by bleeding, digitalis, 
&c. ; hence neuralgia, tetanus, hydrophobia, chorea, 
hysteria, &c. must be reached through the circu- 
lating fluid, by what have been called tonics, iron, 
bark, arsenic, &c, combined with narcotics, and 
with stimulants according to circumstances. 

The jumble of treatment usually adopted in 
tetanus has been such as to defy any calculation 


as to what has done good : opiates and stimulants 
have been counteracted by purgative sedatives — 
hot baths by sedatives — stimulants and narcotics 
by cold baths ; bleeding opposing wine, brandy, 
and opium. In one remarkable case on record, the 
patient recovered, after the nurse, by mistake, had 
given during the night, instead of the medicine, a 
liniment containing a large proportion of laudanum. 
Many cases of tetanus have recovered under the 
employment of warm baths, stimulants, and narco- 
tics ; from which, and various analogies, I adopt 
the treatment by opium in tetanus : if any addition 
be made, it should be that of tonics and stimulants 
when required, not sedatives. We have succeeded 
in finding the mode of curing tic douloureux and 
delirium tremens, which were once opprobria medi- 
corum. Why may we not, by investigation and 
analogies, succeed at length in curing tetanus with 
more certainty ;* or that most dreadful of human 

* Since the above was first published, I have had two cases of 
the disease : the one, locked jaw (trismus) in a debilitated habit, 
recovered with an opiate every night, and a tonic medicine (inf. 
gent. co. c. vin. ferri), with nourishing liquid food and fermented 
liquor. The other, aged seven, traumatic tetanus (locked jaw, 
with opisthotonos in frequent paroxysms), recovered also. The 
treatment in the latter case was (third day of the disease) an opiate 
immediately, to be repeated every night, and a narrow blister 
along the spine. Fourth day the report was, felt better, and 
bowels acted ; but blister appearing to irritate, ordered an enema, 
with Battley's liq. opii gt. xx., ol. terebinth, gt. xxx. every third 
hour ; the second dose produced calm. Fifth day, better, and 
jaws relaxing. Sixth, no opisthotonos since opiate last night ; 
muscles of neck and abdomen still rigid, bowels confined. A pur- 
gative was given by a medical friend, which acted towards even- 
ing, producing griping and return of opisthotonos : I consequently 



inflictions, hydrophobia? — recollecting that, when 
the patient cannot swallow, medicines may be in- 
troduced into the system, either by applying them ' 
to a surface from which the cuticle has been re- 
moved by blister cautery, or internally by the sto- 
mach-pump tube, or by enema. 

I think one point is clearly made out, that 
where there is fever, whether idiopathic, or symp- 
tomatic from local inflammation — loss of power 
from lesion of the nervous system, so that nervous 
influence is deficient, — it is vain to attempt to ex- 
cite action by stimulants, until, from the cessation 
of the operation of the morbid poison or the in- 
flammation, or from a state of collapse, or the 
operation of sedatives, the capillaries of the cineri- 
tious substance have resumed sufficient contraction 
to renew the nervous influence, through which the 
delirium or coma of plethora ceases ; and that, on 
the other hand, when the nervous system is in a 
state of morbid sensibility, combined with the deli- 
rium or coma of inanition, stimulants and narcotics 
are directly indicated ; and tonics should be added 
according to circumstances. 

There is an analogy between the circumstances 
under which trismus nascentium usually occurs, 
and the coma of inanition of infants (p. 82). 

A state analogous to delirium tremens is well 
known to surgeons to occur after accidents and 

ordered an opiate enema, with gt. xxx. ; a second in four hours 
produced calm and sleep. Seventh day, no return of spasms; 
from which time the patient gradually recovered. The ameliora- 
tion as evidently depended upon the opiate as the relapse upon the 
sedative (purgative). 


operations, which induces some to give an opiate 
almost uniformly after an operation ; and many 
formerly used to administer one beforehand. This 
state is occasionally witnessed in hospitals in the 
persons of patients who have been in the habit of 
drinking much fermented liquor : but we must not 
imagine that delirium tremens, or delirium sine 
febre, comes on in those only who use stimulants 
freely; it will occur under a variety of circum- 
stances where morbid sensibility and over-excite- 
ment of the nervous system exists, with exhaus- 
tion, or a debilitated instead of plethoric constitu- 
tion. Cases of this kind occur after parturition, 
from exhaustion, constituting examples of puer- 
peral mania sometimes misunderstood ; in hysteria ; 
in hypochondriasis ; after apoplexy, or wounds of 
the head, when much depletion has been neces- 
sarily resorted to ; after haemorrhage, sensual ex- 
haustion, over-study, and anxiety. It is but within 
twenty-five or thirty years that delirium tremens 
has been recognised and described as a disease 
distinct from inflammatory affections of the brain 
requiring depletion ; and though experienced sur- 
geons knew how to treat the symptoms when they 
arose after accidents and operations, it is only lat- 
terly that they have been identified with delirium 
tremens, any more than the medical cases just 
alluded to. 

In these cases tonics are generally useful ; and 
in some, stimulants with opiates are necessary to 
prevent collapse. In those cases where there is 
want of sleep, opium is generally preferable to sti- 
mulants alone, through its producing the tendency 



to sleep, without so much increasing the force of 
the pulse ; which may, in some instances, such as 
the cases after apoplexy and injuries of the head 
from accidents, be contra-indicated, on account of 
the risk of increasing local injury ; and in which 
the preparations of morphia are most valuable, 
being unstimulating. It is in such cases only that 
the abstraction of blood is admissible, though some 
practitioners still incline to the practice, as well as 
purging, in delirium tremens. The results of my 
experience are decidedly opposed to them. When 
the case is complicated, with diseased brain, there 
may possibly be a necessity for the abstraction of 
blood with caution ; and, in such cases more espe- 
cially, the narcotic must be relied upon, in prefer- 
ence to stimulants : the administration of the nar- 
cotic in a full dose is then indispensable immediately 
after the depletion. 

In many other instances of nervous disease 
besides delirium tremens and tetanus, opium opens 
the bowels : it will do so in diabetes, in which the 
increase of secretion of the kidneys is at first func- 
tional disease from sympathetic morbid sensibility, 
analogous to that in hysteria, or from teething ; it 
will do so in colica pictonum from white lead ; and 
in other cases of colic from sedative. On the other 
hand, it is well known that it will stop the diarrhoea 
of morbid sensibility from sedatives ; so that what 
Celsus said of venesection, we may say of opium, 
that it relieves obstinate costiveness, as well as ob- 
stinate diarrhoea: but these merely empirical asser- 
tions, without explanation (p. 145 et seq,), might 
lead, on the one hand, to the injurious employment 


of sedative antiphlogistic treatment in colic ; or, on 
the other, of narcotic remedies in enteritis, with- 
out sufficient antiphlogistic treatment. 

Many cases of mania are delirium sine febre, 
and would be aggravated by depletory or sedative 
treatment, and the patient would either die, passing 
into the coma of inanition ; or, when the constitu- 
tion began to give way, a change might take place, 
and a febrile relaxation of the capillaries of the 
brain change the entire character of the complaint ; 
as we know deranged persons have become sane 
(or, as it has been quietly denominated, had " a 
light ") before death. This, as to proximate cause, 
is the reverse of what I have elsewhere described 
as taking place sometimes in the crisis of fever. 

Local inflammation sometimes produces fever, 
but at others general or constitutional morbid sen- 
sibility (" irritation "), which are different states, 
but alternate and pass into each other ; so that we 
are obliged to vary our treatment according to cir- 
cumstances. For instance, as in surgical cases, so 
long as the inflammation produces fever, we use 
antiphlogistic means ; but when the character of 
the symptoms changes, and morbid sensibility pre- 
vails, as when tetanus occurs, we must resort to 
narcotics, with tonics and stimulants. 

Again, visceral disease converts ague into con- 
tinued pyrexia. Pulmonary consumption is accom- 
panied by hectic, a mixture of morbid sensibility 
and pyrexia, from inflammation, to which the term 
" irritative fever " also is sometimes applied in sur- 
gical cases. 

Thus we see that inflammations destroy life in 



various ways : some by fever alone, as the acute 
inflammatory diseases — such as pleuritis, and the 
results of accidents ; others, besides inducing fever, 
interfere with the functions of the organs, as peri- 
pneumonia and enteritis ; a third set, again, kill by 
morbid sensibility and wasting, as those which in- 
duce hectic ; and a fourth set by the consequences 
of morbid sensibility alone, as tetanus and hydro- 
phobia. The constitutional disturbance of cancer- 
ous disease has more the character of morbid sen- 
sibility than of fever. Fever is not a higher degree 
of disease than morbid sensibility, since the latter 
may prove fatal without fever, as we see in tetanus, 
epilepsy, &c. This important distinction between 
fever and morbid sensibility will be found useful ; 
and I believe, if followed up, may lead to more 
definite and successful practice in many cases than 
has hitherto prevailed. 

Inflammation, at least so much of it as to cause 
perceptible change of structure, is not absolutely 
necessary for the production of morbid sensibility ; 
for though there be some slight inflammation pre- 
ceding or causing hydrophobia or hysteria; fright, 
as we have observed, will produce the diseased 
state of morbid sensibility in so great intensity as 
instantaneously to produce epileptic convulsions, 
without discoverable change of structure in the 
nervous centres, though morbid sensibility remain 
permanently, as evinced by the returns of the epi- 
leptic paroxysms. We see convulsions arise from 
morbid sensibility, without any degree of inflam- 
mation calling for depletory remedies ; but which, 
on the contrary, are aggravated by them, as we 


find hysteria increased by debility, and hysteric 
convulsions brought on or increased, when, for 
some really inflammatory affection, we are obliged 
to deplete a patient who has tendency to hysteria ; 
and in these cases sometimes delirium, with pain 
of head, comes on, simulating phrenitis, but which 
is mere morbid sensibility, curable by tonics, with 
or without narcotics or stimulants, and not by the 
treatment which cures phrenitis, though the skin 
be flushed. These examples suffice to shew the 
necessity for making a distinction between a state 
of constitutional morbid sensibility and symptoma- 
tic fever ; so much resembling each other in some 
respects, and yet requiring such opposite treat- 
ment for the safety of the patient ; and, moreover, 
as it was shewn that these states run into each 
other, the treatment must sometimes be suddenly 

This may be illustrated by some cases in which 
severe morbid sensibility was the urgent symptom, 
depending, however, upon different causes, and 
therefore cured by opposite treatment. 

A boy was brought into the London Hospital 
who had been confined to bed for some time with 
a swelling of the knee, attended with constant 
pain. He had been for some days under the care 
of Sir W. Blizard when I saw him : he was much 
emaciated, irritable, and languid ; consumed by 
symptomatic feverishness ; got no refreshing sleep 
from opiates ; the pulse 130, thready, or rather 
wiry — very hard. He was too weak to bear more 
leeches to the knee, although that was hot, red, 
tender to the touch, and did not admit of the 


slightest motion, being kept constantly bent owing 
to the pain. The indication was, to take off the 
injecting force, as the vessels could not be other- 
wise relieved ; fifteen drops of tincture of digitalis 
were ordered three times in the twenty-four hours. 
After the second dose, he got better sleep than he 
had from the opiates (p. 115, 1. 10) — the pulse 
becoming immediately slower ; and in less than a 
fortnight he grew stouter, as the swelling subsided, 
and was able to walk home. 

A medical student had swelled knee without 
redness, with great pain, preventing rest. He was 
treated secundum artem by several practitioners, 
amongst whom was one of our best surgeons. He 
had not fever, did not waste, but was tormented 
with pain, and sometimes with painful applications, 
besides occasional purgative and other sedative 
medicine. One night, in despair, he took a sup — 
what he imagined to be about a tea-spoonful (sixty 
or seventy drops) — from a bottle of tincture of 
opium ; after which he slept twelve or fourteen 
hours, awoke free from pain, and very soon walked 
to the hospital without more medicine: 

I may mention another case worthy of atten- 
tion, as not of unfrequent occurrence, and of the 
nature of which it is of great consequence to be 
aware. A young female had, for two or three 
weeks, been treated by bleeding, neutral salts, and 
low diet, for what was called determination to the 
head, supervening upon a supposed pleuritic affec- 
tion. When I saw her, there was jactitation ; sense 
of oppression at the chest; incoherence of speech; 
severe pain of head, occasionally causing her to 


put her hand to it, and to cry out ; intolerance of 
light and sound ; flushed face ; weakness, but not 
sluggishness of the voluntary motions ; — there was 
no fever ; the pulse was jerking, as we find after 
haemorrhage, but not firm; the tongue not foul, but 
white, as we always find it with an empty stomach.* 

* I say, always ; and there is not a more common error than 
to consider this natural appearance morbid. Thus, persons who 
are in the habit of thinking themselves " bilious," and taking 
physic, look at their tongue when they rise in the morning, and 
find it white. A good breakfast will make it look red, unless they 
take a dose of salts, seidlitz powder, or sometimes even whether 
they do or not. The same persons will perhaps put out the 
tongue before a looking-glass just before dinner-time ; and, seeing 
it white, forego a part of the wholesome meal which would bring 
the tongue to the natural colour of redness which it assumes 
after eating, from its natural paleness before eating, unless they be 
gourmands and hypochondriacs at the same time ; in which case 
they will run the hazard of eating, and take a calomel " peristaltic 
persuader" afterwards. I have been constantly in the habit of 
warning my young medical friends to consider, when they see a 
white tongue, what time of day it is, and not to purge for merely 
a white, or more properly a. pale tongue. 

The tongue is constantly very properly inspected in disease, 

I as it affords an evidence of the state of the mucous membrane of 
the stomach and bowels, with which it is continuous. In health it 
j is not of a bright red, but has a pale bloom on its surface, in con- 
I sequence of the tips of the villi or papillae being less injected with 
I blood than the lower parts ; when the stomach is empty it contains 
' less blood, its villi are of course paler, and those of the tongue 
are nearly white : but observe, the tongue is moist ; whereas, 
in the beginning of synocha or pleurisy, or other inflammation, 
the stomach is empty from anorexia, and the tongue is white ; but 
it becomes dryer than from a mere empty stomach, and more or 
less coated, arising from the evaporation of the watery parts of the 
saliva and mucus of the mouth, which leaves the membrane in- 
dued with a more viscid covering than natural. After eating, 
when the stomach is in a state of healthy activity, the tongue 


I ascertained the pain to have been at first in the left 
(p. 147) side; and, from other hysterical symptoms, 
felt satisfied that the present state was clavus hysteri- 
cus of the head, kept up by inanition. She had been 
allowed the day before a little weak chicken-broth ; 
but as she became worse, it was supposed she was 
unable to bear even that, which caused me to be 
consulted. Wine and animal food immediately and 
gradually administered, without any medicine ex- 
cept a few drops of vinum ferri, soon calmed all the 
symptoms of what was called inflammation and de- 
termination to the head (p. 201, line 14) ; and health 
was restored in a few weeks. 

These three cases will illustrate several points. 
We see, 1 . Local inflammation, producing morbid 
sensibility and symptomatic fever ; hence food and 
wine afforded no nourishment, narcotics no rest 
(as they would have done, had there been only 
morbid sensibility without symptomatic fever). 
Cured by a sedative — digitalis. 

becomes redder ; but still it is not of a bright-red hue, which only- 
takes place when the membrane of the primae vise is in a con- 
gested or inflamed state, as in dysentery, in phthisis when colli- 
quative diarrhoea exists, at the termination of typhoid fever when 
there has been (in reality) gastro- enteritis or inflammation of the 
glandulse agminatae, &c. 

In the progress of severe fever, when the secretions are 
suspended, the tongue becomes dry, and the mucus which does 
exist dries, and forms a brownish or blackish crust, and the 
papillae become so much shrunk down to the level of the rete 
mucosum, that when the tongue becomes clean, on recovery, it 
looks glazed and smooth, and some time elapses before the papillae 
rise up again. 

In chronic affections, accompanied with a languid and flabby 
state of the primae viae, a discoloured state of the mucus occurs, 
constituting what is called a foul tongue. 


2. Local inflammation, producing, not fever, 
but general morbid sensibility, chiefly evinced by 
loss of sleep ; no indications for stimulants, seda- 
tives, or tonics, and no want of strength or appe- 
tite. Cured by a narcotic,* which, by procuring 
sleep, gave the nervous system time to regain its 
natural state, so as subsequently to give energy to 
the vessels of the inflamed part. 

3. Local affection (chronic hysteritis), having 
produced, not fever, but constitutional morbid sen- 
sibility — hysteria; debility, arising from depletion 
and want of nourishment ; so that narcotics could 
procure but temporary relief, as they afford no 
nourishment, and sedatives aggravated the deli- 
rium of inanition. Stimulants and food, by giving 
strength, acted as a tonic, and restored power to 
the nervous system, and consequently to other 
parts; and, moreover, the stimulant gave almost 
instant relief, by counteracting the over-sedatived 
state of the capillaries of the brain. 

A chronic painful (neuralgic) state of the brain 
comes on, essentially connected with debility, from 
a variety of causes — fatigue of body and mind ac- 
companied with indigestion, hysteria, malaria in 
aguish districts, &c. ; this state is often misunder- 
stood, and is sometimes with difficulty treated, even 

* We have shewn here how a narcotic alone can effect a cure. 
It is in this way that it cures tetanus, or sometimes with a tonic 
combined. The narcotic, in some instances, gives only tempo- 
rary relief , as in tic douloureux, which it is necessary to cure by 
a tonic ; but we may infer that this relief promotes the cure, 
inasmuch as we have shewn that the relief by a narcotic alone, 
in some instances of morbid sensibility, effects the cure. 


when understood, on account of the opposition of 
the patient in most instances to take stimulants, 
the gradual introduction of which into the system 
is absolutely necessary. Such patients have a dread 
of what they call fulness of the head, which is in 
truth a false sensation depending on morbid sensi- 
bility. The temporary uneasiness, or pain produced 
by stimulants, besides the accompanying dyspepsia, 
renders the use of much persuasion necessary to 
overcome the objection entertained to taking them 
when prescribed. This state often arises in delicate 
persons of either sex. 

A friend of mine came to town for the purpose 
of consulting me, in consequence of what he and 
his medical adviser considered determination of 
blood to the head ; that is, occasional giddiness 
and headache, with some dyspepsia and depression 
of spirits, more severe after breakfast (that is, par- 
ticularly after partaking of a sedative, tea) than 
after dinner. For these symptoms, although a slight 
person, he had been physicked, kept on restricted 
diet, and debarred from fermented liquors, entirely 
with his own concurrence, as he apprehended 
apoplexy. He is a member of one of the learned 
professions ; and it appeared to me that he was 
labouring under a neuralgic state from study and 
over-fatigue. He was convinced of this by my re- 
presentation ; and in about a couple of months was 
restored to health, by gradually resuming a gene- 
rous diet with tonic medicines. Chronic neuralgia 
of the heart, &c. occurs under similar circumstances, 
and requires similar treatment. 


Though keeping the bowels open is useful in 
chorea, and in a variety of nervous affections, 
to promote the digestion, constitutional morbid 
sensibility, hysteria, &c. are always aggravated by 
debilitating agents, especially by abstraction of 
blood ; so that, until food and tonics give strength, 
no cure can result. Now, sometimes in neuroses 
the patient cannot eat, any more than in fever, 
though from a different cause : in fever there is 
anorexia, from a congested state of the mucous 
membrane of the primae viae, and the obtunded 
state of the nervous system in general, and of the 
nerves of the stomach in particular ; in the neu- 
roses, from morbid delicacy of the senses of taste 
and smell, or sometimes from morbid sensibility 
of the primae viae, the first mouthful swallowed 
produces a sense of repletion ; and this nervous 
anorexia sometimes increases the difficulty of dis- 
tinguishing between fever and constitutional mor- 
bid sensibility ; and particularly when the primary 
local affection is in the primae viae, from indigestion 
simulating inflammation of the mucous membrane 

In distinguishing actual (idiopathic) fever from 
morbid sensibility, which is of so much consequence, 
we must not confound that languor which arises 
from nausea and other affections of the primae viae, 
such as diarrhoea, &c, with the languor of want of 
power of volition, from the weakened nervous sys- 
tem of fever. 

Morbid sensibility is an affection of nerve ; but 
nerve, considered in relation to disease, is nothing 
without capillaries — capillaries nothing without 


nerves. The isolated consideration of either leads 
to the error in practice of attempting to relieve the 
vessels at the expense of the nervous system, or of 
resorting to nervous medicines exclusively, to the 
prejudice of the vascular system. 

What I mean by mere nervous medicines is, 
in the common acceptation, anodynes, which al- 
lay sensation for the time, but, having no effect 
on the vascular system, do not cure the disease ; 
neither will tonics have the effect in many cases, 
without skilful adjustment of the secretions, diges- 
tion, &c. 

Apoplexy and paralysis depend upon disease 
of the nervous centres, produced by mechanical 
injury or spontaneous inflammation, or congestion 
only ; and may either be cured, and the paralysis 
pass off, or the usual results of inflammation, tu- 
mours, abscess, effusion, softening, &c. may cause 
the paralysis to be permanent. As the nervous 
centres are hidden from inspection, we cannot dis- 
cover the degree of lesion ; we ought therefore to 
persevere in our efforts to cure, which will often 
at a late period be crowned with success. The 
principles of treating these injuries of the nervous 
system, recollecting the importance of the organs 
involved, and the necessity of energy in acting, and 
care in watching the phases of the disease, are pre- 
cisely the same as the treatment already laid down 
for inflammation in other parts of the body, though 
a mystery was attached to them by the ancients, 
and a much too depletory and lowering treatment 
was formerly indiscriminately employed, and fre- 


quently with an entire neglect of tonics, from the 
fear of their being stimulant, except mercury, which 
was not considered a tonic, though I have shewn it 
to be one of the most powerful (p. 98). 

The principles of treatment, I repeat, have been 
already laid down : active and decided antiphlogistic 
and anticongestive, in acute cases and plethoric 
patients ; in passive inflammatory states, that is, 
with debility of constitution, just barely enough of 
local depletion of vessels ; with tonics, and even sti- 
mulants, when the constitution and the stomach 
require them ; and a long and steady persever- 
ance in the appropriate remedies, with a careful 
attention to the ebb and flow of power in the con- 

The point to which I particularly wish to direct 
the attention of the practitioner is, that there oc- 
curs in old people a paralysis from mere debility 
of the nervous centres, from local congestion, with- 
out either inflammation, softening, tension, rupture 
of vessel, or other organic injury, and which will 
appear sometimes on one side, and afterwards on 
the other. These cases will recover under gentle 
and judicious attention to the constitution, by 
careful non-stimulating support and tonics, includ- 
ing a cautious administration of mercury. I have 
treated many old persons in this way, adding 
digitalis when there has been a strong hard pulse, 
and have effected their recovery from paralysis, 
which had existed, first of one side, and after- 
wards of the other, and had depended upon 
mere temporary local congestion ; which was 
proved, when they eventually died from some other 


cause (general dropsical symptoms, &c), as no 
organic disease of the brain was discoverable. In 
advanced age this chronic disease of the nervous 
centres sometimes produces a sufficiently evident 
paralysis, hemiplegia, paraplegia, or partial para- 
lysis, sometimes combined with affection of the 
sensorium, sometimes not. But the symptoms of 
affection of the spinal cord are also sometimes 
obscure ; and I have seen the muscles of respira- 
tion and circulation attacked periodically, so as to 
simulate (and be called) spasmodic asthma, the re- 
spiration being besides permanently though slightly 
embarrassed. This I have known take place from 
obscure chronic disease of the nervous centres, and 
is precisely analogous to those symptoms which 
arise from the disturbance of the spinal cord pro- 
duced by evident curvatures of the spine, which 
Mr. Hale Thomson has shewn such consummate 
skill in treating.* 

I commenced the pathological part of this work 
with the consideration of the nature of inflamma- 
tion, and the principles of its treatment; and having 
afterwards discussed the nature of the two grand 
groups of diseases which constitute fevers and neu- 

* This mode of practice was commenced in this country by- 
Mr. Ward, and followed up — I might say improved upon — by 
Mr. Thomson, one of the surgeons of the Westminster Hospital. 
It is a union of medical treatment and bodily exercises, directed 
by ingenious mechanical contrivances, but which are not worn by 
the patient, and is similar to the plan so skilfully adopted by 
Stromeyer of Hanover, and in some respects to that of M. Guerin 
of Paris, and others. 


roses, and shewn that, although they are both essen- 
tially affections of the nervous system, they are 
widely different from one another, I propose now 
to add a few observations upon some particular 
diseases. Although, in discussing their proximate 
causes, I may be met by doubts on the part of 
some of my readers, from the novelty of some of 
the opinions advanced — which it may require far- 
ther observation to substantiate, — yet their prac- 
tical utility, or the principles laid down for their 
treatment, will not be founded on a less solid base 
than those which concern the treatment of inflam- 
mation, fevers, and neuroses in general. 

There will have been observed nothing of 
humoralism in the preceding pages ; for though 
I admit the influence of imperfectly assimilated 
nourishment, and its consequent deterioration of the 
blood chemically, producing gravel or scurvy, &c. ; 
I ascribe the effects, whether remedial or noxious, 
of agents, mineral, vegetable, or animal, taken into 
the circulation, to their producing changes of the 
solids. All diseases, in fact, commence, as I have 
already repeatedly said, by disturbance of the func- 
tion of the solid parts of the machine ; and, first of 
all, of the nervous system. This is solidism, or 
neuro-pathology. The nervous system, it is super- 
fluous to repeat, regulates and supplies all with 
energy. There is no organic sensibility, or organic 
contractility, independent of the nerves. Every 
natural impression is received by the nerves ; every 
morbid agent is first felt by, and operates upon, 
the nerves. Inflammation of cellular tissue, bone, 
conjunctiva, &c, through mechanical or other vio- 



lence, result, as we have shewn, in consequence of 
injury to the peripheral nerves and to the capilla- 
ries ; fever from injury to the centres of the ner- 
vous system, which arises either from peripheral 
injury propagated to them, or through lesion by 
miasma, which, by the route of the circulation, 
directly poisons them — most probably by chemical 
combination and alteration, — instantaneously low- 
ering their power or energy. I have shewn through- 
out, that the immediate effect of the lowering of 
the power and energy of the nerves or the nervous 
system is inflammation, or congestion of the capil- 
laries, the first degree of inflammation. The dis- 
eases of morbid sensibility (neuroses), we have seen, 
depend also upon a partial or general derangement 
of the nervous system; arising, when general, either 
from the disordered state being propagated to the 
central organs from a distant region of the body, as 
from a wound, in traumatic tetanus : a poison, in 
hydrophobia : from the uterus, in hysteria, &c. ; or 
originating there through the gradual operation of 
a debilitating cause, as delirium tremens, paralysis 
agitans, idiopathic tetanus, chorea, &c. ; or when 
general morbid sensibility is suddenly produced by 
loss of blood or fright ; — so that neuroses, as well 
as fevers, may be produced suddenly or gradually, 
and, like them, may be either idiopathic or symp- 
tomatic. Fever essentially depends upon a dimi- 
nution of the power of the nervous system — the 
nervous influence, whatever that be, is deficient; 
whereas the diseases of morbid sensibility appear 
to arise, not from a want of sensitive and motor 
nervous energy, but from a derangement of the 


machinery of the nervous centre, or a disturbance of 
that connexion of the nervous centres with the nerves, 
which not only induces, but regulates action. Thus^ 
neither in tetanus nor hysteria is there deficiency 
of power either in the nerves or muscles — as the 
morbidly increased sensibility, and the powerful 
spasms and convulsions shew — but a derangement 
in the direction of it. In fever there is a want of 
steam, or moving power, to use a mechanical illus- 
tration ; in the neuroses the machinery is out of 
order : for instance, when fever is fully established, 
sensibilities of every kind are blunted, both what 
are called animal and the organic; and there is 
debility also of the voluntary and involuntary mus- 
cular systems. In the diseases of morbid sensibi- 
lity, epilepsy, tetanus, neuralgia, hysteria, chorea, 
hydrophobia, &c, either all the sensibilities, animal 
and vegetative, are rendered morbidly acute, or 
the motor energy is distributed to the muscles irre- 
gularly, if not too abundantly ; as we see in chorea 
and paralysis agitans, volition would guide the 
hand to the mouth, but in consequence of the de- 
ranged nervous centre, the hand is thrown in other 
directions, in spite of the will, from the antagonist 
muscles not being under its direction. Or the de- 
rangement of the functions of the perceptions and 
volition, " incidence and reflexion," is simultaneous, 
as in hydrophobia, and some cases of hysteria. In 
fever there is abundant evidence of lesion of the 
cineritious tissue, interfering with its function, the 
generation of nervous energy : in morbid sensibility 
we have only an evidence of deranged actions in 
the distribution of it in the medullary white tissue. 


In morbid sensibility we do not find the faculties of 
the sensorium seriously interfered with, unless when, 
in the advanced stages, a degree of fever comes on, 
and induces the delirium or coma of congestion ; 
or when, on the other hand, inanition produces de- 
lirium, as in haemorrhage, delirium tremens, &c. 

Among the dieases which I intend hereafter 
briefly to discuss, are, first, ague, cholera, and in- 
fluenza — allied naturally to fevers, but which I have 
preferred considering after the diseases of morbid 
sensibility, inasmuch as, following what I have said 
upon these, and concerning the use of sedatives, 
their treatment will be better understood. After- 
wards I shall say a few words upon those affections 
of the skin and fibrous tissues called erysipelas and 
rheumatism, upon phthisis, and on those diseased 
states of the capillaries which produce catarrhs, 
dropsy, haemorrhages, and chronic cutaneous erup- 

I will not enter here into the description of 
ague, as I am not writing for those unacquainted 
with the meaning of the term, but for such as have 
learnt it from lectures, books, or observation ; and 
under the denomination of ague I include remittent, 
as well as what are called intermittent fevers. 

Ague is essentially fever ; it forms, however, a 
connecting link between fevers and neuroses, as a 
considerable degree of morbid sensibility exists in 
it. Ague is. besides, closely allied to Asiatic cho- 
lera and influenza, which are also essentially febrile 
diseases, as I demonstrated in 1832, when we had 
daily opportunities of seeing the former epidemic. 


I consider it. of the greatest consequence to in- 
vestigate these connexions of diseases, which are 
separated by nosologists. In fact, the very close 
examination of them for this purpose increases 
our intimate knowledge of them, enabling us the 
more easily to form a diagnosis ; as a schoolmaster 
distinguishes his scholars, or, more surprising still, 
a shepherd knows the individuals of his flock, 
though to another person they are Kavru, apwrivci 
Tta^voL. By shewing points of essential coincidence 
in diseases which are separated by nosologists wide 
as the poles, we shall account for those individual 
diseases, though antipodes, being benefited by the 
same remedies. Let us just reconsider, what are 
the essential symptoms of fever, whether, in its 
course, it assume the form of intermittent or remit- 
tent, synocha or typhus — those symptoms which 
it is of consequence to remove ; and the efficient 
means of doing so. 

The urgent symptoms are those of debility of 
body, or of body and mind together. Let us not 
have our judgment obscured by the numerous and 
varied non-essential, though sometimes even epi- 
demic superadditions : as in one case there will be 
costiveness, in another diarrhoea ; in one case full 
pulse, in another weak ; in one case hot skin, in 
another cool ; in some cases accidental inflamma- 
tion of one part, in others of another : all of which 
non-essential superadditions must, notwithstanding, 
receive their due share of attention, as aggravating 
the case. But the patient will recover from the 
fever, if we can relieve his debility of body and 
mind : that debility we have shewn to be caused 


by an overloaded state of the nervous centres ; and 
we uniformly see that the only successful means of 
relieving them consist in diminishing the injecting 
force when the pulse is strong, and, at the same 
time, increasing the contracting action of their 
capillaries by antimony, mercury, salines, bark, &c. 
&c. ; or even when the pulse is not too strong, we 
find bleeding sometimes necessary to diminish the 
actual quantity of the load, as the constringents 
alone may not be sufficient to produce contraction ; 
so that, as indicating bleeding, we have much more 
to consider the state of plethora of the internal 
vessels than the state of the pulse or vis a tergo. 
And though emetic substances have an influence 
similar to that of bleeding, in lowering the vis a 
tergo, they are, nevertheless, of most essential ad- 
vantage when the pulse is even almost gone, by 
their immediate constringent effect on the internal 
capillaries : hence it is evident that the pulse, which 
was so long considered as the indication for the 
use of bleeding or sedative medicines, is often alone 
no guide at all;* in which cases the necessary prac- 

* There are so many exceptions to the general rules respecting 
the pulse, that although every one feels the pulse, it requires long 
experience to avoid being misled by it. I will therefore, in this 
place, endeavour to lay down some principles for the removal of 
the difficulties in the way of this source of diagnosis. 

In the first place, as traced above, increase of frequency and 
force (hardness) is produced by inflammation : when the inflamma- 
tion is in an external part, the pulse is usually strong ; when the 
inflammation is in the internal organs, there is not so much evident 
force, the pulse is small and hard, sharp, wiry ; and this wiry feel 
may be very small, yet still evincing a degree of force in the 
contraction of the heart from its morbid sensibility, though the 
organ is felt contracting on a small quantity. Now, we must be 


tice by sedatives, from having been hitherto unex- 
plained, has always been called indirect practice. 
I do not admit this term, and never practise indi- 
rectly : my indications are always founded upon 

on our guard that this same, or even a greater degree of internal 
inflammation may exist, and yet, as shewn above, from depression 
of the vital powers, — as, for instance, when the lungs are gorged 
in peripneumony, — the pulse may feel quite feeble, from the blood 
not being arterialised, and therefore not stimulating the heart to 
contract. In such a case, venesection, by allowing freer circula- 
tion through the lungs, will increase the stimulating properties of 
the blood, and raise the pulse and vital powers. Here we ascer- 
tain the condition of the organs by auscultation, the colour of the 
lips, and other symptoms, and decide in opposition to the pulse. 

On the other hand, various neuralgic states produce a frequent 
and strong pulse, which, though ordinarily an evidence of inflam- 
mation, indicating bloodletting, must be disregarded, as bloodlet- 
ting would be injurious. In these instances we must be guided 
much by the previous history of the case ; and be cautious not to 
be misled by the symptom of pain, if the patient be nervous, and 
if the various usual accompaniments of the inflammation, which is 
simulated, do not present themselves. Thus, in hysteria, symp- 
toms sometimes mistaken for peritonitis arise. In the hysteri- 
cal affection, less obstinate constipation and less dryness of skin 
exist; the tongue is generally less dry, though it may assume 
almost any appearance ; but the pulse in hysteria is less wiry 
than in peritonitis : the same may be said of the pulse, skin, and 
tongue, in the assemblage of hysterical symptoms resembling pleu- 
ritis. In inflammation of the heart, which is so often unfoundedly 
dreaded by hysterical patients, the pulse is soft, like the pulse of 
acute rheumatism, as the inflammation renders it weak ; so that 
it allows of distension, and has not power to empty itself. When 
we find the pulse of natural frequency, full and hard, we must 
suspect organic disease of the heart ; for unless that exist, the 
pulse is full and soft, or frequent and hard, or frequent and soft. 
There is a frequent soft weak pulse, with dilatation of the left 
ventricle : but the practitioner must make himself acquainted with 
the peculiarities depending on the diseases of the heart itself, as 
one means to prevent his being misled by the pulse. 


physiology, as I have explained them up to this 

We must again separate clearly in our mind 
phenomena from causes : for instance, rigors, cold 
shrunken skin — the cause of which was said by 
Cullen to be spasm of the extreme vessels ; the 
contracted state of the latter is, however, mere 
effect, not cause : convulsions, again, are the mere 
result of morbid sensibility, and have no direct 
connexion with the fever; on the contrary, they 
have been considered by experienced men rather 
favourable in the eruptive fever of variola. 

What are the steps from the invasion of the 
poison till the development of the fever ? The first 
is a debilitating influence on the nervous centres : 
the mind is at this time clear, though languid ; the 
pulse is small, the skin cold, and the limbs tremble, 
or are convulsed, from the morbid sensibility of the 
nervous centres, evinced also by pain in the head 
and spine. From the weakness of the circulation, 
therefore, all the external capillaries contract, not 
by spasm, but by their natural contractile action — 
through not being sufficiently injected ; the blood 
is consequently congested in the internal parts of 
the trunk, producing nausea, and other disturbance 
of the primse viae, augmented by the morbid sensi- 
bility of the sedatived nervous centres, sometimes 
causing vomiting and diarrhoea. 

Now, this is the first stage of fever ; in which, if 
the dose of poison has been sufficient, death has been 
known to occur, and that very suddenly, not only 
in the " Bombay fever," but, as it has been stated, 
in the severe yellow and other fevers, attacked with 


which patients have died at once, without any re- 
action or rallying ; as, for instance, soldiers have 
dropped on parade, and died immediately: the 
heart having been unable to propel the blood to 
the brain, fatal syncope or asphyxia has ensued.* 

This stage of depression may last for minutes, 
hours, days, or weeks, as evinced in the ephemeral 
continued fever, regular agues, and those irregular 
agues vulgarly called " dead " ague, to be described 

The next stage of fever is commonly named 
the hot stage ; but as that designation is totally 
inapplicable to typhous fevers, I prefer the term 
relaxed, as that implies the actual state of prostra- 
tion of nerves and capillaries, which is so evident, 
and which I consider the proximate cause both in 
u synocha " and " typhus." The severity of this 
stage will depend entirely upon the dose of poison 

* From the histories of fevers, and from observation, it ap- 
pears that the poison of continued fever is generated by animal 
matter, as in crowded ships, jails, &c. ; the poison of ague and 
remittent fever by vegetable matter, some cryptogamous species, 
as those fevers prevail chiefly in situations where these are met 
with, such as marshes, uncultivated places, &c. For instance, 
those parts of Rome in which the malaria exists are among 
deserted buildings, where, in the shade, cryptogamia abound. In 
London we have many cases of ague arising from malaria, in 
places inhabited by the poor, where there is warmth, shade, and 
manure, favourable to fungi, &c. When marshes are drained and 
cultivated, the cryptogamia are destroyed, and agues are not ge- 
nerated. The tremendous remittents of hot climates appear chiefly 
where the ground is at times covered with water, and where, after 
the rains have subsided, it remains half- wet, abounding in rank 
and decomposing vegetable matters, especially where there are 
uncleared woods. 


and state of constitution; whether, for instance, 
the individual will return to a state of health im- 
mediately, with but a slight degree of languor for 
a few hours after the chill ; or whether the pheno- 
mena of a continued fever, or the hot fit of an 
ague, will result, owing to the poison having been 
sufficient to cause the more permanent relaxation 
of the capillaries of the nervous centres. 

It has been previously shewn how sedative in- 
fluence ultimately produces relaxation, which state 
now ensues in the nervous centres ; and it will 
depend upon how much they are relaxed, whether 
the fever will be hot or not. If too much relaxed 
to allow of their secreting nervous influence, as 
when the fever is typhous, the circulation and 
respiration will not have power to produce a full 
pulse and hot skin ; if otherwise, we shall have 
flushed hot skin, as in continued fever and in ague. 
But in either case the skin will be reinjected ; for 
even in typhous fever, though the heart be weak, 
the superficial capillaries, having lost their tone 
from deficiency of nervous influence, relax, and are 
refilled even by the weak heart with a dusky blood. 
And a similar state may be seen in some agues, 
where, after the chills, there is a typhous state, 
and a livid colour of skin, with dreadful langour, as 
may be observed in individuals with ague in the 
Pontine marshes. Thus, even in ague, the student 
must not expect to find always the hot stage of the 

These are the only two stages of fever and ague. 
There is no third stage of ague : the sweat which 
succeeds the hot stage is nothing but an indication 


of renewed secretion by the capillaries, which, after 
having lost their tone, and been consequently in a 
relaxed, distended, non-secreting state, renew their 
secretion on being restored to a normal condition ; 
and, of course, as they are returning from a relaxed 
state, they will pour out fluid sweat at first, until 
recontracted sufficiently to secrete insensible per- 
spiration — a mere vapour. 

It has just been mentioned that the ague exists 
frequently without shewing the hot stage ; in fact 
the patient remains in a continued state of depres- 
sion, with a languid circulation, cold livid skin, and 
the sensorium more or less oppressed. It is very 
common for patients in this state to present them- 
selves at the hospital, and, when questioned, not to 
be able to give any account of their symptoms, as 
is also the case with them when they apply during 
the cold stage : in either case the practised physi- 
cian will see at once that he has before him the 
subject of ague. Sometimes the patient with irre- 
gular ague just described will answer at once, when 
asked what is the matter with him, that he has the 
" dead ague," the name given by the peasants to this 
state of disease, which they know originates amongst 
agues ; and which they also know sometimes turns 
to regular ague, that is with rigors (" shaking ") and 
sweating. In such a case, when I have asked a pa- 
tient who did not use the term dead ague, " Have 
you the ague ?" the answer has been, " I wish I 
had ; I should be much better if I could shake 
out " (outright). 

It is an interesting subject for a student to 
watch the effect of a tonic, such as bark or arsenic, 


on one of these cases, as the uniform evidence of 
improvement is, that a paroxysm of regular ague is 
produced as a step towards the cure. 

I became acquainted with this circumstance in 
the first year of pupilage. A patient was admitted 
into the hospital with cough, looking very ill and 
sallow ; he was ordered some calomel and squill 
mixture, with a blister to the chest. The effect of 
the calomel, the comfort of the hospital, and change 
of air, was, that the next morning he felt better, and 
was soon after attacked with a fit of regular ague. 
This was an early and useful exemplification of the 
"larvatas, or masked agues." Plentiful doses of 
bark (quinine had not then been heard of) cured 
the ague and cough together.* Men of experience, 

* A lady consulted me on account of troublesome cough, 
uncertain as to expectoration, occasionally rather dry, and some- 
times producing towards evening difficulty of breathing, which 
lasted generally through that night until towards morning, when 
profuse perspiration came on. She and several of her friends 
apprehended tubercular consumption, some of her brothers and 
sisters having died of that disease ; other persons told her it was 
spasmodic asthma. The tongue was very slightly coated, the 
pulse above 100, and the skin rather dry : these were some of 
the symptoms of consumption ; but the stethoscopic signs of 
either asthma or tubercles were absent, and I remarked that the 
colour of the skin was rather muddy and sallow. As she had 
been my patient before she went abroad, I asked if she had not 
had " the fever " (ague) in the West Indies, whence she had re- 
turned about five months. She said she had, and had not felt 
quite strong ever since ; upon which I decided that she had 
caught cold (catarrh) upon the dregs of an ague, and therefore 
gave her quinine to cure both together, and a little mucilage with 
squills and syrup of poppies to pacify the cough when trouble- 
some, and allowed her to go into the country. In about a week 
she returned, saying she felt much better, but had had a regular 


especially in aguish districts, have seen all the 
modifications of these larvatse, such as aguish apo- 
plexy, aguish paralysis, aguish sore eyes, aguish 
rheumatism (called intermittent neuralgia,* &c), 
and which are well described by Macculloch. 

fit of the ague the day before. I desired her to double the 
quantity of the quinine, and assured her that she would be well 
in another week. She objected, that a mutual medical friend 
had told her she must leave off the sulphate of quinine, as it 
was not safe to take it with such a cough. By following my 
directions, however, she was quite well in ten days, and has con- 
tinued so now five years. 

* In the last note I gave a case of masked intermittent; I 
may here offer one as* a caution against confounding inflammation 
with neuralgia. A gentleman, aged forty-five, caught cold, which 
was followed by a cough and severe pain in the head, shooting 
from the right eye to the back of the head, which was aggravated 
when he coughed or walked, and at those times extended to the 
top of the head ; pulse generally about 100, hard. When this 
state of things had existed some weeks, his medical attendant 
called in a celebrated veteran physician, who prescribed guaiacum 
for the pains, considering them rheumatic. After this he was 
cupped on the neck to fourteen ounces, without relief. In about 
a month he found the sight of the eye weak ; the pains became 
excruciating, especially periodically from one o'clock a.m. till six, 
and he got no sleep ; even during the day the pain would not 
permit him to read or write. Another physician was now called 
in, who administered anti-neuralgic medicine and laxatives for 
about three weeks unavailingly. The gentleman's ordinary me- 
dical attendant consulted me at this period, and I recommended 
bleeding, considering that there was chronic inflammation of the 
membranes of the brain ; but the patient refused to allow it, 
partly on account of feeling so weak, but principally because he 
had had an increase of pain after the cupping, though I expressed 
my opinion that that was merely because the cupping had not 
been sufficient. My diagnosis was soon confirmed by the occur- 
rence of paralysis of the eyelid and of all the muscles of the eye 
except the trochlearis (which may be accounted for by the root of 


Ague frequently degenerates into continued fe- 
ver ; and I must add a few words upon the nature 
and variety of the degeneration. When the fever 
is of the simple continued kind, synochous, with 
hot skin, the ague is called a remittent ; when it is 
of a typhous character, it assumes the form I have 
described as dead ague. 

Ague constitutes the link between fevers and 
neuroses ; but in ague, besides the state of morbid 
sensibility of the medullary tissue, we have abun- 
dant evidence of the plethoric congestion of the 
cineritious tissue also ; so that a compound treat- 
ment becomes necessary, — different from that of 
the neuroses, as well as from that of fevers. The 
sedative treatment which suits fevers suits agues, 
and more especially the irregular ones ; for the 
irregular dead agues, or remittents, which are de- 
teriorated agues, will be brought to the regular 

its nerve lying about a finger's breadth out of the line of the 
other nerves where the inflammation ran) ; there was also a de- 
gree of deafness, besides numbness and pricking in the side of 
the nose, cheek, lip, and teeth. A consulting surgeon was now 
called in on account of the eye, who recommended blisters and 
mercurial medicines, but without success ; as, however, he coin- 
cided with me as to the propriety of bleeding, the patient at last 
gave way to our united entreaties, saying that he thought himself 
too weak to bear it, but he could not exist under the pain, and 
therefore consented to lose " a small quantity of blood." We, 
however, got away about twelve ounces, which relieved him so 
much, that he did not object to being bled again repeatedly for 
some weeks, and occasionally for five or six months, until he was 
quite well, as he has continued now for about seven years. The 
eye and its muscles have recovered their functions ; but there is 
still a disagreeable extra sensibility in the skin of that side of 
the face. 


state (if not cured) by sedatives : and this is also 
the case with influenza and cholera, which are 
closely allied to the ague. The regular agues, 
which approach more closely to the neuroses, will 
be, like them, cured by tonics alone, and, like the 
neuroses, bear stimulants much better than fevers ; 
remittents, influenza, or cholera, which are curable 
by sedatives, require sometimes the addition of 
tonics in convalescence. In cases of fever, and in 
all kinds of ague, influenza, and Asiatic cholera, 
there is an internal congestion of the viscera, in- 
cluding the nervous centres, which is relieved by 
sedatives; though in regular ague and cholera, 
from peculiarities which may be explained, stimu- 
lants are borne with more or less impunity. 

In regular ague, constitutional morbid sensibi- 
lity is prominent. There exists, it is true, a great 
degree of congestion of the nervous system, as well 
as of the viscera, during the paroxysm, succeeding 
to a morbid poison ; but rarely is real fever pro- 
duced. There is the pyrexia, equivalent to what 
occurs in hysteria, but seldom actual fever — not 
that loss of power in the capillaries of the nervous 
system which prevents the generation of nervous 
influence ; for in ague, stimulants, unlike the effect 
they have in fever, do not produce the coma of 
plethora — the nervous centres being little injured, 
though debilitated, are relieved by the stimulant 
narcotic tincture of opium ; and consequently fresh 
energy is communicated to the capillaries, even in 
the hot stage, by which they resist the heart's in- 
jecting force. Thus we may explain the apparent 
inconsistency of using venesection and laudanum 


simultaneously in ague, which has been recom- 
mended by some. The venesection, which we 
know produces the best effects, is not to relieve 
inflammation, but congestion ; and hence is not 
often necessary, except, for instance, to relieve 
some organ, as the brain or lungs, which may be 
evidently suffering during the paroxysm, through 
its having been previously in a morbid state, as we 
see in the hemiplegic modifications of ague, which 
form an exception to the use of laudanum. In the 
latter the paroxysms are accompanied by coma or 
hemiplegia, the brain being previously unsound, 
though the pulse is weak ; as in the state of debi- 
lity after apoplexy and wounds of the head ; and 
as the aguish congestion passes off, the hemiplegia 
or coma passes off also, until the renewal of the 

If severe cases of Asiatic cholera be taken in 
time, they may be cured by acting upon a similar 
principle, viz. by relieving the internal congestion ; 
unless indeed, as sometimes takes place in continued 
fevers, the individual have received so powerful a 
dose of the epidemic poison as will certainly prove 
mortal, despite any mode of treatment. If the 
blood, however, have begun to coagulate, the pa- 
tient is dead to all intents and purposes, even 
whilst breathing and speaking, and the heart act- 
ing ; for I have heard the sound of the valves of 
the heart contracting just before death in cholera, 
when I am satisfied clots were already formed in 
the ventricles : at this stage, of course, neither 
sedatives, stimulants, bleeding, nor any thino- else 
can produce any effect. The slight or middling 


cases of cholera have a tendency, like ague, to 
remit of themselves ; and hence whatever treat- 
ment had been adopted, the practitioner used to 
think he had cured them: and thus I have been 
repeatedly told by practitioners that they had 
found the true remedy for cholera. But the next 
time I met them there was a long face upon men- 
tioning the specific. Any person, however, who 
will treat the disease on principle may defeat it 
by a variety of weapons, only using them with 
energy, — antimony, all sorts of salines, acetate of 
lead, sulphate of zinc, common salt and water, 
even cold water,* calomel —but the last, if used in 
the quantity necessary to be sedative, afterwards 
produces havoc on the mouth. Stimulants in mo- 
deration do little good or harm, except the evil of 
augmenting the secondary fever, or actually induc- 
ing it ; as the hot or febrile stage of many cases of 
cholera would have been scarcely perceptible, if 
stimulants had not been used freely during the 
collapse, which might have been safely combated 
by the sedative constringents. Considering, then, 
the constringent effect of the various sedatives, 
antimony, mercury, lead, neutral salts, alkalies, 
&c. &c, we can understand how, as they ultimately 
coincide in the indication of cure, they have been 
adopted by different persons to effect the same 
purpose; and each, finding some particular sub- 
stance efficacious in certain cases, has subsequently 

* The constant desire for cold water in cholera is an example 
of natural instinct which is thwarted by man in his wisdom ; 
while every thing hot, both as to caloric and stimulants, is often 
poured into the patient. 



used that in preference to others. I think, how- 
ever, I have done something towards reconciling 
apparent contradictions, by pointing out the prin- 
ciples which ought to guide us. 

Before I had an opportunity of personal obser- 
vation, I was lead, by reading, to make a too-limited 
estimate of the symptoms of cholera, referring 
chiefly to the affection of the stomach and bowels 
(old English cholera morbus) as the cause of the 
collapse. When, however, I encountered the ene- 
my hand to hand, I saw at once that it was like 
ague ; not merely as regards its epidemic and mias- 
matic origin, but almost, if not altogether, an ague 
of a fresh type ; and I often thought of what the 
great Sydenham candidly said of his first encoun- 
ters with new epidemics. I inculcated, therefore, a 
treatment in cholera successfully adopted in ague, 
and borne out by the previous experience of Ken- 
nedy, Lefevre, and others, i. e. bleeding, with eme- 
tics and neutral salts, but modified and combined 
with opium and stimulants in some of the stages. 
Subsequently, both in the cold stage of ague and 
cholera, I have depended much upon antim. tar- 
tariz.* with or without neutral salts, and resorted 

* In order to exemplify more definitely the mode of treatment, 
I will give a couple of cases from my note-book ; taking, first, one 
with all the marked symptoms of the worst form of the disease 
from which patients can recover. 

"March 14th, half-past ten, p.m. Patient aged 40, had been 
out attending to business, and rode in an open carriage from 
about 3 till 5 p.m., in good health and spirits, as remarked by 
his wife. About 6 p.m. attacked with pains in limbs, back, and 
abdomen, chilliness and coldness of the skin, with frequent vomit- 
ing and purging; supposed to have had thirty watery motions 


less to bleeding, and with more flattering success. 
The rationale is explained p. 168 et seq. 

Upon this analogy between cholera and ague 

up to the present time ; the matter passed like rice-water, with 
white farinaceous-looking sediment ; no urine, thirst, but tongue 
clean, moist, and cool; pulse 110, very feeble; countenance cada- 
verous, skin livid (blue-black), hands cold, and the skin shrivelled ; 
fingers crooked like a bird's claws ; severe pains from cramps in 
hands, arms, feet, legs, neck, and trunk both back and abdomen ; 
voice shrill ; complains chiefly of the cramps, cold, and nausea. 
Ordered antim. tartariz. two grains, magnesia sulph. half an 
ounce, in half a pint of water, a table- spoonful to be taken every 
half hour. 

" 15th, two, a.m. (three hours from last visit.) All the symp- 
toms relieved : no sickness, only two more motions, of the same 
appearance ; cramps gone from hands and arms, and less in the 
trunk — still in the legs ; hands less cold, does not now feel chilly ; 
began to feel warmer along the back after the second dose, i. e. 
little more than half an hour after commencing the medicine, 
though the previous efforts of his attendants with hot flannels, 
bags of hot bran, &c, had not produced the slightest effect, and 
were laid aside by me on my first arrival. 

" Eleven, a.m. All the symptoms relieved : pulse full, soft, 
76 ; still rather thirsty, and skin warmer than natural, and dry ; 
tongue clean, rather whitish ; has had refreshing sleep within the 
last hour — none before ; feels only weak, no cramps, but pain in 
muscles on motion ; only three motions like the former during 
the last nine hours, amounting to about two pints ; none for the 
last three or four hours ; no urine ; slight nausea after the last 
dose of the medicine. Let him take only half a table -spoonful of 
the mixture every two hours, and five grains of calomel imme- 

" Six, p.m. One yellow, foetid, feculent motion, and nearly a 
quarter of a pint of natural urine. 

" Eleven, p.m. Has had some sound sleep, feels comfortable, 
but weak ; and muscles feel tired and rather painful after the 

" 16th, mid-day. Feels well, but weak; pulse 84, full, and 



I would address a few words to men of practical 
experience. What is called " the fever," so well 
known in India, beginning with chills and shivering 
(rigors), &c, followed by intense heat, and then, in 
favourable cases, by perspiration, with relief of symp- 
toms, pursues occasionally a different course ; for, 
as we also observe in ague in this country, some- 
times sweat does not occur, but the skin remains 
hot, in a state of continued or remittent fever. 

soft ; skin still warmer than natural. Ordered to continue the 
mixture every four hours, with half a grain of sulphate of quinine 
each time." 

Having alluded to the very slight cases, I may subjoin one : — 
" Called at ten, p.m., to a lady. She had been attacked in the 
morning with a shivering, slight nausea and diarrhoea ; about six 
watery motions (rice-water and white sediment), unaccompanied 
by griping, no cramps, but some pain in calves of legs ; the shi- 
vering had continued, and she had taken a hot bath without any 
relief; she then went to bed, and could not get warm until after ; 
drinking many cups of mixed tea (a sedative), when profuse per- 
spiration came on, with relief, in which state she was at my visit. : 
There had been a dry heat before the perspiration, but even then 
a tendency to shivering ; and she remarked, that upon stretching I 
out the hand, or even turning the head round, a sense of shivering 
was produced (morbid sensibility, independent of temperature). 
I recommended her merely to drink more cool tea if thirsty ; and, 
in case of return of diarrhoea on the following morning, to take a 
dessert- spoonful of the above saline antimonial every half hour. 
It did return, with nausea, and the second dose removed it 

In these cases will be found an exemplification of the various 
peculiarities above pointed out in treating of cholera. I wish to 
illustrate the principle of treating the disease, and not to assert a 
preference of my own remedies ; for in the absence of tartar eme- 
tic or Epsom salts, I could have treated the case with the sedatives 
employed by other practitioners, acetate of lead, ipecacuanha, 
common salt, &c. 


Who that has seen much of the cholera does not 
recollect some cases with this routine ? Again : 
"the fever" of India, when it goes through the 
ague-stages, does not, like our agues, continue for 
weeks ; a second, or at most a third paroxysm, is 
usually fatal in the severe cases which the physician 
cannot check. Who has not seen patients die in 
cholera after they had become quite hot, the fever- 
heat exciting fallacious hopes ? There was once 
an epidemic, the " Bombay fever," which is said to 
have destroyed the patients in the cold stage ; and 
it was inferred that, had the patient lived, the hot 
stage would have come on. Who will decide now 
whether that was cholera or ague ? for, though 
called fever, the description agrees with cholera. 
Whoever has had much experience in ague has 
seen all the modifications of cholera ; the cold 
stages, with convulsions (spasms) — spasmodic cho- 
lera ; ague, with nausea and diarrhoea, and of 
course little ' or no urine — the purging cholera ; 
ague, with blueness of the skin, and shrivelled fin- 
gers, like a drowned person — blue cholera ; ague, 
passing into continued fever — a common termina- 
tion of cholera ; &c. &c. 

One of the most successful modes of treating 
ague is to give an emetic in the cold stage, fol- 
lowed up in the intervals by bark, or other tonics, 
with calomel, purgatives, &c. pro re nata. I have 
frequently shewn my clinical pupils that bleeding 
in the cold stage is perfectly safe, and resembling 
in efficacy the operation of an emetic ; but as vene- 
section is not often necessary, and a feeling exists 
against it, I do not frequently resort to it, as the 


emetic will usually suffice ; and I content myself 
with bleeding the patient, when indispensable, be- 
tween the paroxysms. It is pretty well known 
how valuable an adjunct bleeding has been in 
cases of cholera ; but the evidence is complicated, 
from the variety of treatment which has been 
adopted in conjunction with the bleeding. The 
treatment of cholera by antim. tartariz., which I 
found most efficacious, proved remarkably so, ac- 
cording to the reports of several talented medical 
friends, in London, Paris, and elsewhere. I had 
no means of shewing the treatment to my clinical 
pupils, as cholera was excluded from our hospital ; 
but as many of my former pupils were placed as 
medical attendants in the various temporary cholera- 
hospitals, I had, independently of private practice, 
but too frequent opportunities of investigating that 
dire disease, from which we know not how long we 
may be exempt. 

It would be quite beyond the limits and scope 
of this work to enter farther into the description 
or treatment of cholera ; but in Dr. James John- 
son's Med. Chirur. Review, April 1832, will be 
found ample valuable information on the subject. 
At. p. 627 there is a note by the editor especially 
worthy of notice, shewing that the gruel or rice- 
water evacuations which constantly occur are not 
specific, but merely the result of all the bile and 
faeces which had been in the intestines being car- 
ried away ; or, as he says, " ex nihilo nihil fit :" 
and I may add that, so far from a " discharge of 
bile completing cure," the discharge of bile is 
merely the ordinary event, evincing remission of the 


disease, or convalescence; and a renewed paroxysm 
of diarrhceal cholera would soon wash that away 
too. This clear-sighted and experienced physician 
also inculcates the use of sulphate of quinine, as I 
have done, on principle. In fine, I may repeat, 
that I consider cholera an essentially febrile* dis- 
ease, whether it assume the intermittent, remittent, 
or continued form ; that it is not a new disease, 

* One or two striking facts illustrative of the probable con- 
nexion between fever and Asiatic cholera have been mentioned to 
me since writing the above. A gentleman practising in a densely 
populated neighbourhood by the " water- side," where the latter 
disease, which there scourged for an unusually long time, was 
preceded and followed by numerous cases of synocha petechialis, 
denominated by him " spotted fever," — had noticed in 1830-31 
that the prevailing fever was accompanied, besides pulmonic dis- 
turbance, by some soreness of the throat, and a peculiar eruption 
upon the surface of the body, " something between the eruption 
of scarlatina and purpura." He was surprised, during the preva- 
lence of cholera, on observing that, in some of his patients, after 
they had passed through the diarrhceal, vomiting, and blue stages 
of Asiatic cholera, the consecutive fever was accompanied, not 
only by the same degree of sore throat noticed by him in the 
fever of the preceding years, but also by a precisely similar erup- 
tion. The same gentleman corroborated my opinion that, sub- 
sequently to the cholera passing over our island, the epidemic 
" spotted" fever was ushered in and accompanied by symptoms 
of derangement of the intestinal mucous membrane (diarrhoea, 
&c), rather than of the pulmonic (bronchitis), which was not- 
ably affected in 1830-31 (p. 150, note). Nor had the probable 
affinity of the miasmata of influenza and cholera escaped him : 
the practice of a patient follower of the Sydenham school, and a 
diligent investigator of nature, is highly worthy of being recorded. 
He found the most successful treatment of cholera to be that of 
small doses of calomel with anodynes in the first stages, and 
neutral salts during the febrile state : copious libations of cooling 


but the same described by Sydenham in 1669, 
and subsequently by Frank — the same which occurs 
in Madras, Bengal, Italy, Russia, England, and else- 
where ; that when I, as above, use Sydenham's terms, 
" fresh type" and " new epidemic," I do so, not as 
implying a new disease, but, as he does, a modified 
form of a disease according to the " constitution of 
the epidemic in the year in which it occurs ;" just as 
he speaks of the great peculiarities assumed by the 
small-pox at different periods, although the iden- 
tity of the disease is incontestable. 

We have been suffering from another scourge, 
the influenza, which is somewhat akin to cholera, 
or rather perhaps is of a mixed nature, between 
the cholera or ague and Sydenham's " new fever" 
(synocha petechialis), and which may be rapidly 
cured by an emetic, followed by saline antimonial 
medicine, and, as soon as the febrile state is passed, 
light tonics. I have only to observe on the subject 
of bleeding in influenza, that it is seldom necessary, 
except when the epidemic is complicated with in- 
ternal inflammation of the lungs and bronchial 
tubes, or other parts (as it has been in many cases) ; 
and then the patient will run great risk of dying, if 

drinks in both. In influenza, he stated that he was unquestion- 
ably most successful with mild "antimonial treatment" — small 
repeated doses of tartar emetic. 

A physician who has paid great attention to the eruptive fever 
(" exanthematous," synocha petechialis) which has prevailed so 
much the last few years, not only in these islands, but on the 
continent, has also informed me, that at St. Petersburgh many 
patients, during the consecutive fever of cholera, presented the 
identical eruption of the epidemic fever. 


not bled. This I mention particularly, because I 
have so often heard it asserted, that the influenza 
does not bear bleeding or " lowering" treatment.* 

The benefit of sedative (antiphlogistic) treat- 
ment in these cases, and in various fevers, indicates 
the propriety of using the sedative narcotics when 
an anodyne is required to allay cough or procure 
sleep during their progress : hence, though many 
use opium, syrup of poppies, or laudanum, I prefer 

* Of this I may offer one or two examples. A young woman 
presented herself as an out-patient of the London hospital, with 
influenza of forty- eight hours' standing, flushed, chilly, headache, 
pain in chest, soreness of throat. I took the opportunity of shew- 
ing the pupils the antiphlogistic treatment of influenza : sent her 
direct to the clinical wards, had her bled to a pint, and gave the 
saline antimonial mixture and calomel. This treatment my assist- 
ant followed up with the addition of leeches to the chest. She 
recovered speedily. 

Another case is that of a particular friend, who is in the 
habit of what he calls curing himself — which I translate, taking 
the wrong medicines, so as to render his case more complicated, 
before he sends for me. He wrote to me a note during the preva- 
lence of the influenza. " I have been taking ***** 
for two days ; nevertheless I am so much worse that you must 
come and do something decided for me." I found him labouring 
under an aggravated attack of influenza, flushed, catarrhal, head- 
ache, incipient short cough, pain at epigastrium. I took imme- 
diately twenty ounces of blood from the arm, and gave him a 
quarter of a grain of tartar emetic "and a drachm of Epsom salts in 
an ounce of water every two hours. With this treatment, and 
sundry doses of calomel, rhubarb, and magnesia, which he took 
besides without my directions, he speedily recovered from the 
influenza, which is said not to bear " lowering" treatment. 

The effect of the antimony and salts on cases of influenza, 
without local inflammation, is to take off the painful chilliness 
and nausea, exactly as pointed out in the case of cholera related 
p. 243. 



the preparations of morphia, or hyoscyamus, as 
has been formerly explained. 

Notwithstanding that rheumatism exists in 
organs of which, as pointed out by Bichat, the 
fibrous tissue constitutes the major part, I do not 
consider that arthritic disease, rheumatism or 
gout, depends upon a lesion or inflammation of that 
tissue in particular, as is often supposed. The fibres 
of the tendons of muscles, the fibrous tissue of liga- 
ments, and cartilage, like the osseous tissue, must 
not be viewed apart from the connecting cellular 
tissue and the accompanying nerves and blood- 
vessels ; and we shall be thus led to conclude that, 
however important they are to the animal eco- 
nomy, by serving as the basis or characteristic 
material of individual organs, they are second to 
the highly important cellular tissue and the arte- 
ries and nerves in the production of pathological 
phenomena. By this explanation the student will 
understand how it happens that the comparatively 
lowly organised structures, ligaments, fascias, arti- 
cular capsules, &c, precisely like the more highly 
organised skin and mucous membranes, are so inti- 
mately connected pathologically with the general 
condition of the individual : he will not wonder 
that indigestion should produce an attack of rheu- 
matism or gout, or that either may be suddenly 
translated to a vital organ, constituting what is 
called metastasis, and thus prove rapidly fatal ; or 
that cold and damp, alteration in the electrical 
states of the atmosphere, should be so keenly per- 
ceived, through the occurrence or increase of dis- 


ease, before even the ordinary senses have been 
able to apprise the individual of the change ; thus 
making a rheumatic patient, what he is not inaptly 
called, a living barometer. 

Some persons are led to suppose that rheuma- 
tism, being inflammation of the fibrous tissue, as it 
is called, is something quite peculiar, quite differ- 
ent in its nature from inflammation of other parts. 
When it is considered, however, that it is the same 
inflammation as exists in other parts, the same 
lesion of nerves and blood-vessels, the symptoms 
being modified in consequence of the nature of the 
aggregate tissue, the practitioner will be led to ra- 
tional treatment, according to the principles I have 
laid down for the treatment of inflammation in any 
part of the body ; in every instance of which, he 
has not to act for a name, but to reflect upon the 
proximate cause of the disease under consideration, 
and the constitutional condition of the patient ; for 
he will have noticed in how many instances of dis- 
ease bearing the same name he has had to operate 
with different means, and according to what, in a 
superficial view of the subject, might be looked 
upon as opposite principles. 

There are forms of chronic rheumatism which it 
is extremely difficult, if at all possible, to distinguish 
from neuralgia; so direct is the connexion between 
the nerves and rheumatic disease. Indeed, I be- 
lieve that all rheumatism commences with lesion 
of the nerves of the part : to which it may be ob- 
jected, that in acute rheumatism the other tissues are 
red and swollen. Even so ; the process of inflam- 
mation begins by functional, if with no physical 


derangement, in the nerves, and spreads, owing to 
the diffusion of the nervous tissue, through the cel- 
lular tissue of the skin, muscles, sheaths of tendons, 
pericardium, &c. This affords an explanation of 
the phenomena, and of the utility of the remedies 
employed : many cases are curable by tonics, while 
most are relievable at all stages by narcotics ; some 
imperatively requiring bleeding, a few injured by it : 
the perception of which last-mentioned fact was 
the reason that bleeding was quite out of fashion 
at Edinburgh when I visited it ; so much so, that 
patients with their wrists and ankles swollen, and 
the chest oppressed, were not bled, because, as 
was truly asserted, bleeding sometimes caused the 
convalescence to be tedious. No doubt this hap- 
pened when discrimination was not used. All 
my life I have seen men prescribing for diseases 
by name : one man bleeds always in acute rheu- 
matism, another never, or scarcely ever ; one gives 
emetics and bark in all cases, another mercury, 
another colchicum, &c. &c. ; one man finds digi- 
talis of great use in rheumatism, another stares at 
his assertion. From what has been already said on 
the subject of inflammation, it may be deduced why 
and where these remedies suit ; why, for example, 
digitalis and bleeding will procure sleep better 
than opium when the brain is plethoric and feverish ; 
and, on the other hand, that wine and other pro- 
ducts of fermentation will procure sleep better than 
even opium when there is a state of inanition.' 

I must beg pardon of my senior readers whilst 
I set down a few directions for the juniors, in 
further explanation. 


Do not neglect to bleed in acute rheumatism 
(rheumatic fever), if with a plethoric appearance 
you have the external redness and tenderness, com- 
bined with oppression at the chest, indicating tend- 
ency to pericarditis, or if there be symptoms of 

Do not bleed in acute rheumatism, unless eme- 
tics and other treatment have failed, if there be 
only external pain and swelling, and a patient not 
strong, lest you have a slow convalesce nee, as any 
one may expect if a patient be bled unnecessarily. 

But, on the other hand, always have the fear of 
internal inflammation, " metastasis," in your mind's 
eye, or you may have no convalescence at all, but 
death for want of bleeding. If your patient gets 
severe pericarditis, you will either have death soon 
with fever, as I have known happen from neglect 
of bleeding, or a lingering death from adhesions and 
enlargement of the heart (such as may be seen on 
the shelves of every museum), with dropsy. 

Never neglect, in acute rheumatism, to examine 
the chest, and inquire about it ; for the patient will 
scarcely ever complain of it, even when affected, in 
consequence of his attention being drawn off to 
the severe pain in the limbs and muscles of the 
trunk. Conviction has been forced upon the medical 
world, that in rheumatic fever the heart uniformly 
participates in the disease; though "metastasis" 
to the heart is not said to have taken place until 
symptoms of serious lesion of the organ are evinced; 
but the peculiar pulse of rheumatic fever declares 
the state of the organ. It is irritated sympatheti- 
cally as in other acute diseases, hence the pulse 



is more frequent ; but being itself affected by the 
rheumatism of its fibro-serous tissue, it is weakened 
in its action ; hence it does not empty itself, caus- 
ing the full soft pulse, — full, because there is much 
blood, and soft, because the action is not energetic. 

Opiates are useful in almost every case of rheu- 
matism, particularly in order to procure sleep, as 
sleep restores the nervous system ; tonics are bene- 
ficial, as already explained, by their influence on 
the nerves ; emetics operate favourably as sedatives, 
diminishing the vis a tergo, without debilitating. 
And, besides, to relieve the external inflammation, 
antimony, colchicum, &c, in doses short of pro- 
ducing nausea, when circulated to the capillaries, 
act like the tonics commonly so called, as already 
explained. The efficacy of veratria and the allied 
alkaloids rubbed on the skin and absorbed, is simi- 
lar to the internal use of colchicum. 

In referring rheumatic inflammation to the 
nerves, I have only gone a step farther than some 
who call certain kinds of it neuralgia. The excit- 
ing cause of rheumatism is usually cold and damp 
together, not either alone ; intense cold will seldom 
produce rheumatism, if the atmosphere be dry ; but 
if the skin have been perspiring previously, so that 
it or the inner garment is damp, rheumatism re- 
sults ; warm damp does not produce it. A cold fog 
or rain will produce the effect, though the person 
has not been previously perspiring. Moisture ap- 
pears to exercise a peculiar effect on the electric 
state of the nerves ; but if the parts be warm, that 
is counteracted, — the cold and damp together are 
noxiously sedative. Every person can recollect 


illustrations. The softer and more vascular tissues 
are not so easily contracted to a noxious degree as 
the dense fibrous tissue ; hence the latter is the 
first to suffer from the sedative damp and cold. 

Erysipelas also commences in the nerves. Cold 
air does not produce the inflammation, unless the 
part have been previously warm and damp, and 
then a continued stream of cold air will produce 
erysipelas. Slight erysipelas of the face or ear is 
frequently produced in this way, and called by the 
peasants a blight or blast. 

When erysipelas is about to appear, the part 
becomes painful long before there is any red- 
ness ;* it begins, in fact, with lesion of the nerves. 
It is well known that severe pain long precedes 
any blush or other evidence of inflammation in 

* Some time ago I had an interesting exemplification of this 
fact, having been called to see a youth with superficial inflammation 
of the arm, supposed to have been brought on by a liniment. It 
was erysipelas of that kind which on the waist is called shingles 
(herpes zoster), exactly portrayed in Willan's plate. The appli- 
cation could not have produced it, as that was a mild soap lini- 
ment ; but the interesting fact is, that the severe incipient pain 
of the erysipelatous disease, commencing on the Monday, was 
supposed to be rheumatism, and the arm rubbed ; and no redness 
was perceived till the Wednesday evening, when the liniment was 
blamed. In this way I have known leeches falsely accused of 
bringing on erysipelas, having been applied to the temples for the 
severe pain and heaviness of the head of its incipient stage : al- 
though in some individuals with " irritable skin," or in elderly 
people, the bite of a leech, the prick of a pin, or the bite of a non- 
poisonous insect, particularly if the injury be where the tegument 
is lax, may produce a degree of erythematous inflammation, but 
not genuine erysipelas. 


This circumstance of inflammation resulting 
from cold and damp has been commonly attributed 
to checked perspiration ; because it has been tho- 
roughly ascertained, empirically, that perspiration 
had preceded the injury. But the reason is as I 
have stated — the perspiration acting merely as / 
adjunct to the cold. In ague, we know that the ner- 
vous system is injured by malaria, which is a well- 
authenticated cause of rheumatism also, which re- 
sembles ague in phenomena as well as cause, being 
often intermittent ;'* and to carry the analogy to the 
treatment, there is none more efficacious for either 
than that of Haygarth for rheumatism — emetics, 
followed by bark ; and the emetics repeated if the 
symptoms are obstinate. But it will be said that 
malaria exists in hot climates. I answer, observe 
how careful Italians and natives of other warm 
climates are to avoid night-air. Their nights are 
often piercing cold, and the air deleterious ; whereas 
our night-air is not so. The sedatively poisonous 
effects of cold and malaria are powerfully increased 
by their acting together. Pleurisy and peritonitis 
arise in the same way ; and pleurisy, as well as 
pericarditis, is not so often " metastasis" as has 
been thought, but an inflammation synchronous 
with the rheumatism. 

Now, on the other hand, we must be on our 
guard, as there are cases of apparent neuralgia 
(neuritis) which are chronic inflammation of serous 
membranes, and which I have cured by active 

* Macculloch's work on this subject is very interesting and 
instructive ("Essay on Remittent and Intermittent Diseases. 



bleeding and antiphlogistic treatment, as if they 
had been but a day old, though they had existed 
for many months. Those that I have seen have 
occurred chiefly in the meninges of the brain, or 
in the pleura or pericardium. How are they dis- 
tinguishable from neuralgia ? By the accompany- 
ing obscure pyrexia, malaise, altered temper and 
appetite, frequent pulse, and generally bad sleep 
(p. 237, note). 

I may in this place bring forward some further 
exemplifications of the principles of applying reme- 
dies. Without referring to what has been said upon 
delirium tremens (p. 205 et seq.), it would be diffi- 
cult to understand how, in some cases, genuine 
narcotic or hypnotic medicines fail of procuring 
sleep. I have before mentioned (pp. 106, 193,) 
that when digitalis, a sedative, is indicated, it acts 
as a soporific, whereas opium in that case would 
fail ; sometimes, on the other hand, when fully 
indicated, a stimulant will procure sleep. 

Thus, in a case of subacute rheumatism (recent 
severe sciatica), extending down the leg, with pain 
on pressure, the secundum artem treatment, by col- 
chicum, calomel, and low diet, did not relieve. 
Moreover, morphia did not procure rest ; for the 
night before I was consulted about the patient, a 
grain of muriate of morphia (equal to three, if not 
four, grains of opium) failed. I found the patient's 
pulse frequent, but moderate as to strength ; the 
fauces relaxed, and the tonsils swollen and rather 
purple, shewing a debilitated constitution. I ordered 



bark and soda, instead of the medicines previously 
used, and some wine at dinner ; and instead of the 
morphia, half a pint of good ale at bed-time. The 
patient slept well ; and the next morning the ton- 
sils were of a good, that is, an arterial, colour, and 
less swollen. The rheumatic pains were relieved 
much within thirty hours of the change of treat- 
ment. Such cases may be considered the triumph 
of principle : both the rheumatism and sore throat, 
as inflammatory diseases, were considered to require 
antiphlogistic remedies, with which morphia was 
consistent ; but the inflammations being accom- 
panied by debility, stimulants proved antiphlogistic, 
and therefore procured sleep (p. 152, note, and p. 
105). It may be said that this was a case of rheu- 
matism of the sciatic nerve, curable, on Haygarth's 
plan, by bark. Be it so : but the practice adopted 
was unique (and deduced a priori from the princi- 
ples I have laid down), — to give wine and ale to 
cure inflammation, which was evinced by pain on 
motion and pressure, frequent pulse, restlessness, 
and a recent sore throat in addition ; but the pulse 
was not hard, the tongue was not foul, and the 
skin was not dry. I trust the student will learn to 
prescribe on principle, and not empirically apply a 
nostrum to a disease because it has a name. If 
diseases could be so labelled, the practice of physic 
would be as easy as some young gentlemen, judg- 
ing from the little attention they pay to the oppor- 
tunities afforded them in the hospitals, seem to 
think it, but which they bitterly regret in after-life, 
when they incur the responsibilities of practice. 


I would contrast with the last-mentioned case 
one in which a sedative was required, followed up 
by the same tonic treatment of bark. 

An old friend and pupil asked me to visit his 
child, about which he was very anxious — it being 
much sunk from a large suppurating tumour of 
the submaxillary gland, from which there was an 
erysipelatous inflammation spreading across the 
lower part of the face. The application of leeches 
the day before had not checked, but, by increasing 
the debility, seemed rather to augment the malady, 
as the inflammation was spreading. In this case, 
tonics were absolutely necessary to give power to 
the capillary arteries (to increase their action) ; but 
we could not wait for the slow operation of tonics 
(pp. 92, 105 et seq.), as the erysipelas would have 
spread ; I therefore gave an emetic, and requested 
the parent to watch how its action would produce 
a paleness in the then increasing boundary of in- 
flammation. The emetic did stop the inflammation 
without debilitating ; and the tonics, with nourish- 
ment, prevented the renewal of it ; so that there 
was only the trouble of the tumour remaining, 
which had suppurated before I saw it. Some calo- 
mel was also given, as part of the tonic plan, to 
act on the capillaries, not as a purgative — the child 
having been well purged before. 

It may be asked why I made the distinction in 
this case, and gave a sedative instead of a stimu- 
lant, as in the preceding. The former was neur- 
algia of the sciatic nerve, and not likely to be aug- 
mented by an increase of the force of the heart, 
especially if sleep could be procured, which was 


our object. The second was not neuralgic, but 
inflammatory — relaxed capillaries evident to the 
eye, which the vis a tergo would have increased, as 
may be deduced from the instant good effect of 
taking it off by lowering the pulse by the sedative 
(emetic) ; and this shews the great value of eme- 
tics as a substitute for bleeding in cases where 
bleeding would be required if it could be borne ; 
and also how powerfully emetics must assist bleed- 
ing, where they would not be sufficient without it. 

Here, in two words, is the epitome of the treat- 
ment of erysipelas — emetics and tonics. Tartar 
emetic, to check the inflammation, which being 
one of a debilitated diathesis, though benefited by 
leeching or bleeding at the moment, much evacua- 
tion will even increase the tendency of the disease 
to return, as is known by experience. Tonics, in- 
cluding calomel, take away that tendency or dis- 
position of the disease to return ; and the latter, 
by its tonic effect on the liver, promotes the diges- 
tion, and consequently the strength of the patient, 
who must be well nourished after the paroxysm. 
Practitioners well know that it is the nature of 
erysipelas to return periodically like gout, or even 
more frequently, and thus undermine the constitu- 
tion. I can assure them from experience that the 
plan I have laid down, persevered in, and modified 
according to circumstances, will eradicate it. 

I must here repeat a caution against being de- 
ceived by symptoms arising during the administra- 
tion of a remedy (tonic, for instance), which are 
frequently ascribed to it, though not really depend- 




ing upon it. It is frequently observed that after a 
person, especially a child, has taken a purgative on 
account of indigestion or acidity, the patient be- 
comes even hotter before the bowels are relieved ; 
but this is merely the effect of the transit of the 
acrid matter through the intestines, equivalent to 
that heat and flush which is produced by the aci- 
dity of indigestion in children, which commonly 
relieves itself by vomiting. In some cases of debi- 
lity, especially in convalescence from acute diseases, 
as measles, scarlatina, &c, quinine or other tonics 
are absolutely necessary to prevent a strumous 
state from coming on ; but as heat of skin con- 
stantly supervenes in these cases from weakness of 
the digestive organs, it requires the confidence of 
practical experience to persevere with the tonic 
(thought by some to be "heating"), which will 
strengthen them, and prevent the recurrence of 
the heat.* 

* I must trespass on the reader's patience now to give an 
example, on the other hand, of the failure of empirical practice, 
which is so common. Several years ago, one of my pupils, just 
before commencing practice, called on me to examine his chest 
with the stethoscope. He thought he had hypertrophy of the 
heart, from constant, annoying, forcible palpitation. On inquiry, 
I found that he had pain after eating, without acidity ; and slug- 
gish bowels, without deficiency of bile. " You have been over- 
anxious about your examinations," said I, " and have got atonic 
indigestion." " So I thought at first," he replied ; " but as I have 
tried every thing for that, and lived very regularly and sparingly, 
and taken no fermented liquor, I begin to fear hypertrophy." My 
prescription was, " Go home, eat and drink, and take half a wine- 
glass of vinum ferri three times a day, and no purgatives ; and 
when you come again this day week I will examine your chest." 
He called on me in a week to say he was well, and laughed when 


We have now to inquire into the nature of 
dropsy, which is an undue deposition of watery 
(serous) fluid by those capillary vessels of the 
serous membranes and of the cellular tissue which, 
in a healthy state, supply merely sufficient to keep 
those parts moist. Dropsy is inflammation (" leuco- 
phlegmasia"), or congestion (p. 26) : the proximate 
cause of the acute or chronic being the same — 
a weakness, and consequently giving way or en- 
largement of the capillaries concerned. 

I cannot agree with those authors who consider 
congestion to exist only in the veins, and to differ 
from inflammation in the cause being mechanical. 
We know that a mechanical obstruction in the 
circle of the blood must cause congestion as surely 
as damming a river-stream, and that not solely in 
the veins ; but there are causes of dropsy which 
do not act mechanically, and mechanical causes 
which produce venous congestion for a long time 
without dropsy resulting ; as it is not until the 
capillaries themselves are congested, in conse- 
quence of relaxation from loss of nervous energy, 
that dropsical effusion commences, which occurs 

I asked him if I should examine his heart. Now comes the empi- 
ricism. After some three years he consulted me about one of his 
patients, who had " symptoms exactly like his own, but the vinum 
ferri did no good." " You have not yet mentioned the sex." 
" A young lady." "Is she very pale then?" "Quite the con- 
trary," &c. " Have you forgotten our clinical wards ?" " Oh, I 
suppose you would recommend a drachm of cubebs three times a 
day, and a grain of calomel about twice a week." To which I 
assented. He called on me in about a month to let me know 
that, by persevering in those remedies, the action of the heart was 
become as " regular as a pendulum." 


often when there is no mechanical obstruction — as 
in acute anasarca from cold, which is inflammatory, 
as its name implies, and which occurs often in 
robust persons, like acute hydrothorax (sometimes 
misnamed empyema), from pleurisy ; or acute 
ascites, from peritonitis; or in chronic anasarca, 
chronic hydrothorax, &c. from chronic uterine and 
other affections in the young or old, or even from 
a bad compound fracture of a limb. 

I hold relaxation of capillaries to be sufficient 
for the explanation of the phenomena of dropsy ; 
and in like manner as I denied arterial action to 
be increased in inflammation, so I deny that it is 
necessary to refer, as many do, to a diminished 
action in the absorbents as a cause of dropsy. I 
consider the action of the absorbents to be uniform, 
and that it is not necessary to suppose any altera- 
tion as to absorption as a cause either of inducing 
or removing dropsical effusion; for, considering the 
action of the absorbents to be uniform, merely to 
take up and carry off what is offered to them, it is 
evident that in case of too great a quantity of fluid 
being poured out, the absorbents will not be equal 
to the taking it up fast enough ; but when we act 
upon the capillaries, so as to check their exhala- 
tions, we know that the absorbents, continuing 
their action, will gradually carry off the overplus 
of effused fluid ; and we know that we can re- 
strain the effusion from capillaries in two ways, 
either by constringing them, or by allowing less 
fluid to go to them. But of the absorbents we 
know no demonstrable mode of directly altering 


their action.* I believe, therefore, that the medicines 
which are commonly said to increase the action of 
the absorbents act on the capillary vessels so as to 

* Indeed, the only mode in which we undoubtedly affect the 
action of the absorbent — and that is indirectly — is evinced by 
some of the phenomena succeeding the experiment of the intro- 
duction of a poison by incision or injection into the cellular tissue, 
or serous sacs of an animal, or even into the stomach. It has been 
noticed, that an increase or diminution of the plethoric state of the 
animal affects the rapidity with which the poison is absorbed, or 
produces its poisonous effects. Thus, if it be bled after the admi- 
nistration of a poison in either of the above-mentioned modes, poi- 
sonous effects will be evinced earlier than in another animal which 
has not been bled. On the contrary, injection of warm water 
(98° Fahr.) into the veins of the animal under such circumstances 
retards the operation of the poison. In opposition to the opinion 
that, in such experiments, the rapid operation of the poison arises 
from absorption being in any way accelerated, it might be stated, 
that by depletion the animal is weakened, and that consequently 
a smaller quantity of the poison then suffices to produce the per- 
nicious results. But it can hardly be maintained that that expla- 
nation will apply to the well-known fact of persons who do not 
labour under disease, but have been bled whilst in health as a pre- 
ventive, (which in former times was so much in vogue,) having 
the absorption of chyle so greatly increased that their robust ple- 
thoric state becomes augmented, and fat accumulates in most 
parts of their frame. It certainly appears that the function of ab- 
sorption, or that phenomenon evinced in the living body which 
out of it is called endosmose, is, according to physical laws, modi- 
fied by the nature and quantity of the fluid contained in the system 
of hydraulic tubes — the elastic arteries and capillaries, and the 
veins, — the diminution of whose contents facilitates the emptying 
of the absorbents into them, and of course quickens the flow in 
the absorbent ; in other words, increases absorption. This in- 
creased activity of the absorbents, through the depletion of the 
blood-vessels, is an admirable adaptation of structure and function 
of parts of the living body to the intended end. How wise a pro- 


check their deposition ; and that this is the true 
account of the removal of dropsical swellings by 
the action of mercury and other medicines, which 
either cause an alteration in the action of the ca- 
pillaries, so as to stop their depositions, or, as elate- 
rium,* for instance, by causing evacuation, actually 
diminish the quantity of matter supplied by the 
arteries to the exhalants, whilst the evacuation in- 
creases the current in the absorbents. 

Dropsy is most frequently not a primary disease, 

vision for the more speedy reparation of accidental loss of the fluid 
parts of the machine ! 

The knowledge of these facts suggests the immediate utility 
of depleting remedies — venesection, salines, antimonials, purga- 
tives, elaterium, &c. even in dropsies not ostensibly inflammatory; 
hence the utility of depleting remedies combined with tonics, and 
the reason why, in cases of poisoning in the human subject, no 
depletion should be resorted to for checking the inflammation of 
the viscera until the whole of the poison has been voided or 
extracted from the stomach. 

* It is surprising how many medical men are afraid to use 
elaterium : having perhaps in early life ascertained that its 
effects are great, they think they are violent, which, however, 
is incorrect, if it be judiciously administered. If the eye be 
made to weep by an actual injury, such as sand, or a blow, or 
other cause of inflammation, the effect is very different from the 
weeping produced by holding an onion before it. The analogy 
is perfect between the operations of these two substances : the 
elaterium produces a weeping from the exhalants of the bowels, 
which carries off dropsical fluid without the slightest injury to 
the membrane of the intestinal canal. It is just as erroneous to 
fear employing elaterium to relieve the chest and other parts of a 
patient who is oppressed and suffocating with dropsy, as to fancy 
that a water-logged leaky ship could not bear the action of the 
pumps which draw the water from its hold. Some of my medical 
friends into whose hands this will come have seen the effects of 
elaterium in saving a sinking vessel. It is to dropsical cases that 
elaterium is peculiarly applicable, and not in those where merely 


but a symptom — a state of debility of the nervous 
system, and consequently of the capillaries, induced 
by disease of some organ, and increased, as in organic 
disease of the heart, liver, lungs, &c, by mechanical 
obstruction of the circulation. The partial sudden 
effusions which sometimes take place from inflam- 
mation of a serous membrane, as from the pleura 
constituting the empyema of Laennec,* (which, as 
above observed, is not the empyema of Cullen), 
should rather be called inflammatory effusion than 

Dropsy may be induced by any protracted dis- 
ease, which, by morbid sensibility or slow fever, 
robs the secretory organs of their nervous energy, 
as the kidneys, skin, and intestines, but particularly 
the kidneys and skin. And when they cease to 
secrete, the redundant fluid oozes from the capil- 
laries, which are not merely overloaded, but weak- 
ened in consequence of the deteriorated state of 

purgatives are indicated ; in fact, if elaterium be continued as a 
purgative after the dropsy has been removed, it begins to distress 
the patient, who, up to that time, felt decided relief from, it. 

* I take this opportunity of acknowledging our obligations to 
Laennec : any man who practised for some years (as I did) before 
the introduction of auscultation, and felt the difficulty of diagnosis 
in many diseases of the heart and lungs, can estimate the blessing 
it confers, by enabling us to distinguish the varieties of these affec- 
tions. Compared with what we now know of diseases of the vis- 
cera in the chest, the degree of information attained five and 
twenty years ago was but " darkness visible." It appears unge- 
nerous to detract from Laennec by saying he has not assisted us 
much in prescribing : he has done every thing in helping us 
to distinguish the disease — the application of remedies depends 
upon our own skill afterwards. As for any objection to ausculta- 
tion, I have never known any one who understands it who is not 
glad to avail himself of it. 


the nervous system ; and unless we can restore 
energy to the nervous system, so as to check exu- 
dation, by giving tone to the capillaries, we in vain 
resort to tapping, or diuretics, or cathartics such as 
elaterium, to evacuate the dropsical fluid, as it will 
speedily re-accumulate. 

Thus dropsy is not to be treated as an isolated 
or single disease, except when for a time, to prevent 
a patient from being overwhelmed by the fluid in 
the cavities, we turn our whole attention to getting 
rid of it, either by tapping or by profuse evacua- 
tion, as by hydragogue purgatives or diuretics, and 
other medicines. 

When we see a patient with dropsical swellings, 
our great object must be to cure the disease which 
produced the dropsy — the latter being but a 

It is true that both are sometimes cured by 
attending to the one symptom alone, as when 
dropsy is the consequence of inflammatory dis- 
ease of the lungs, pericardium, or liver ; in which, 
besides bleeding, squills and digitalis are employed 
as diuretics, with purgatives to evacuate the fluid 
by the kidneys and bowels, some form of mercury 
being at the same time used empirically. Here, 
although the whole attention be given to the 
symptom of dropsy, the treatment is also appli- 
cable to the local affection ; and in such a case 
the primary and secondary disease are often cured 
together. By referring to local inflammation as 
the origin of some dropsies, we can understand 
how, in many cases, the abstraction of blood be- 
comes a most useful assistant in the cure, as well 



as the advantage of bloodletting for the mere 
object of taking off the injecting force of the heart, 
when the heart and capillaries do not balance in 
power ; as, for instance, when other diuretics fail, 
from the congested state of the kidneys, venesec- 
tion often proves the most powerful diuretic, as we 
have mentioned that it is sometimes a most efficient 
adjunct to cathartics. 

On the other hand, in dropsy of broken-down 
constitutions, as well as in inflammations with 
failure of the vital powers, by referring to the 
influence of the nervous system in giving strength 
to the capillaries, so as to enable them to contract, 
and resist the distending force of the heart, we can 
understand how tonics, and, in some instances, sti- 
mulants, as wine acting as tonics, as above explained 
(p. 105), increase capillary action, and restrain the 
effusion, when evacuation would sink the patient ; 
so that dropsy, like inflammation, is cured by oppo- 
site treatment, according to the state of the consti- 

A fruitful source of dropsy is disease of the 
heart — organic alteration, especially hypertrophy, 
and imperfect valves or contracted openings, the 
effect of the hard pulse from hypertrophy being to 
cause over-distension, at the same time that the 
capillaries, from diminished nervous energy, are 
weakened ; for the obstruction or regurgitation 
from imperfect valves causes pulmonary conges- 
tion, and consequently deficient arterialisation of 
blood, as well as cerebral congestion, both dimin- 
ishing the generation of the nervous energy ; from 
which result capillary congestion (evinced by dys- 


pncea, livid lips, &c), tendency to coma, diminished 
secretions, dropsical effusions. 

In those cases where the cause is an organic 
alteration which cannot be removed, we must be 
cautious in not endeavouring to do too much at 
once by over-active treatment, as the strength 
must be supported, though depletion be necessary. 
Whatever increases the action of the heart, by 
adding to congestion, diminishes the vital powers ; 
so that there must be a constant exercise of skill 
to preserve a balance between heart and capillaries. 
Digitalis, hydrocyanic acid, &c. (see p. 116), will 
restrain the former, whilst the latter will be much 
assisted by the tonic medicines which do not sti- 
mulate, and at the same time help to support the 
strength under the operation of the occasionally re- 
quired evacuants and sedatives. 

This leads us to the rationale of another sym- 
ptom — haemorrhage from the mucous membranes,* 
which, as well as purpura and p. hemorrhagica, 
takes place under the same circumstances as 
dropsy — the exhalants, from atony, and sometimes 
from over-repletion, as in epistaxis, allowing blood 
to exude instead of aqueous fluid ; and even the 
capillary exhalants of the serous membranes some- 
times allow blood to escape, which we find mixed 

* " Haemorrhages" are represented in the systems of some noso- 
logists as a distinct class of diseases. I have endeavoured at once 
to acquaint the student with their true nature, and thus assist him 
in the diagnosis and treatment of disease. The haemorrhages, like 
dropsies, are but symptoms of organic disease, sometimes of the 
part whence the blood comes, at other times of remote organs. 


with the dropsical lymph upon tapping, or after 
death. Enough has been said to account for the 
exhalants of mucous membranes becoming so de- 
bilitated as to allow blood to weep from them. It 
used to be commonly said, and is still thought by 
many, that when blood is vomited, or passed down- 
wards, or coughed up, that there has been a rup- 
ture of a blood-vessel ; but though this does some- 
times happen, the most common source of the blood 
is from the network of capillaries. 

In amenorrhcea, the (chronic) hysteritis from 
which it proceeds produces sympathetic morbid 
sensibility of the stomach (occasionally of the 
bronchi, &c, p. 147) ; consequently relaxation and 
congestion of the mucous membrane, ending in 
haemorrhage, sympathetic vomiting of blood, some- 
times periodical (catamenia vicaria). Chronic hepa- 
titis, the local inflammation or congestion of the 
intestines in fever, and other affections, also bring 
blood from the surface of the primae viae. Bron- 
chitis causes spitting of blood, sometimes tolerably 
copious, without rupture of vessel. Now in all 
these cases the symptom of haemorrhage must be 
combated as dropsy, according to the state of the 
constitution : hence the distinction of active and 
passive haemorrhages. The active must be treated 
by antiphlogistic means, bleeding and sedatives ; 
the passive haemorrhages, such as those at the 
close of fever, and many cases of menorrhagia, 
most directly and safely by opiates, with astrin- 
gents of course in both cases. And even after 
active haemorrhages are subdued, the patient must 
not be kept too low, as some strength is required 


to produce the reparation of capillaries which have 
been injured, when there has really been inflamma- 
tion. But I have shewn (pp. 202, line 10, 216, line 
25,) the nature of cases which constantly occur, in 
which there is no disease but morbid sensibility, 
and in which the depletion and deprivation of 
food, adopted through mistaking the symptoms for 
inflammation, have sometimes brought the patients 
to death's door, if not over the threshold ; and 
even if they escape with their lives, they may 
suffer years of debility and discomfort before the 
stomach can again properly bear the presence of 
food, or the nervous system recover its tone. How 
often has it occurred to me to be called in by 
young medical men in breathless haste, who were 
really in a state of great anxiety about a patient, 
generally a female, sometimes after parturition, in 
one of those "mimose" affections just alluded to, 
resembling inflammation, apprehending the greatest 
danger ; when instantly, on looking in the patient's 
face, and feeling the skin, I have whispered, 
" There is nothing the matter with her." " But 
what is to be done ?" " Nothing." " But she will 
die, if she goes on this way." " Not if you abstain 
from active treatment." 

The inflammation or relaxation, producing in- 
crease of secretion from mucous follicles in different 
parts lined with mucous membrane, denominated 
catarrhs, may be combined with fever or not: 
as in catarrh of the air-passages, diarrhoea, or acute 
dysentery ; hence relievable either by stimulants 
with opium, on the one hand, or by sedative treat- 


merit (including bleeding) and opium, on the other. 
If you ascertain that there is not fever, you may 
stop simple troublesome catarrh (p. 107 et seq.) 
or diarrhoea, with stimulants or opium, either in 
recent or chronic cases, as in chronic dysentery 
also ; but if there be active inflammation and 
pyrexia, as in bronchitis, influenza, and acute dy- 
sentery, an antiphlogistic (sedative) treatment must 
be adopted with the anodyne. 

The terebinthinate gum-resins, and balsams, 
which have been found useful in the catarrhal 
states of the urethra and vagina, have the best ef- 
fect also in catarrh of the bronchial tubes, and none 
more so than Venice or common turpentine, the 
efficacy of which is increased by combining it with 
powdered senega-root in pills. The senega has as 
much influence on the capillaries when circulated 
to them as ipecacuanha ; and as it is less emetic, it 
can be given in larger quantity. 

The term catarrh, acute or chronic, is so pecu- 
liarly applied to cough, from whatever cause it 
may arise, that I think it necessary to make some 
observations on the nature and treatment of coughs. 
Independently of recent cases of inflammation in the 
chest, as cough is a symptom of consumption (tu- 
bercular disease of the lungs, to which the term con- 
sumption is properly restricted), it always produces, 
when long-continued, an anxiety in the minds of 
friends ; but cough may arise from a variety of 
causes which only medical men can ascertain, and 
which even some of them often fail to distinguish, 
from not having paid sufficient attention to auscul- 
tation ; besides which, young practitioners are often 


not aware of the variety of circumstances which 
may produce a long-continued cough. I have been 
consulted for severe coughs of some duration, in 
more than one instance, which I discovered to de- 
pend upon a cause at first sight insignificant, as, a 
chronic inflammation, with hardened wax, in the 
ear ; and though most persons are acquainted with 
the fact, that irritating the internal part of the 
ear will produce coughing, these cases had passed 
through the hands of several medical men pre- 
viously, without this cause being detected, although 
there was a degree of deafness, which attracted my 
attention to it. Chronic enlargement of the ton- 
sils, and accumulation of a white curdy matter in 
their ducts, will produce cough; and a relaxed 
elongated uvula, it is commonly known, induces 
a most distressing continued cough : and in all 
these coughs, when long continued, the membrane 
of the larynx and trachea, inflamed by mechani- 
cal irritation, gives out extra mucus, thus produc- 
ing expectoration, with occasionally even streaks of 

Such cases occur both in males and females, 
giving rise to suspicion of consumption ; but the 
most common cause in females is hysteria, often so 
slight that scarcely any, if any, discoverable irregu- 
larity or derangement of the functions of the uterus 
is evident, and yet the morbid sensibility of the 
bronchia and larynx (p. 147) resulting thence, pro- 
duces cough, with alarming symptoms, not merely 
expectoration, as in the cases just alluded to, and 
which is chiefly from the continued mechanical 
irritation of the cough, but also spitting of blood 



the occurrence of which gives additional cause of ap- 
prehension of consumption. The mode of treatment 
of the former cases is obvious to all medical men 
as soon as the cause is discovered, according to the 
old adage ; and, as to the latter, I have found no 
difficulty in curing this imagined consumption by 
directly attacking the primary disease* with such 
remedies as turpentine, iron, cubebs, aloes, qui- 
nine, assafoetida, &c. ; and anodynes, with squills, 
&c, to allay the morbid sensibility of the bronchia 
and larynx ; at the same time supporting the 
strength by animal food and fermented liquors, 
which are too often forbidden, from the practitioner 
supposing the symptoms to depend on inflamma- 

* The diseases of the liver not being so readily cured, the 
secondary liver- coughs, or asthma, do not so quickly yield. 
Before the publication of Laennec, it was much more common for 
practitioners to be guided by obvious symptoms, and prescribe for 
them. Liver-disease, as is well known, produces cough : this is 
dry at first, but in time the irritation of the bronchia produces 
expectoration ; and then, if the liver-disease be accompanied by 
hectic, as is commonly the case, I have known it mistaken for 
phthisis. In other cases, the indurated enlarged liver produces 
pain in the back, and sudden starting up, and difficulty of breath- 
ing, after the patient has been some time asleep, in the middle of 
the night, with dry cough, which subsides after the patient has 
been sitting up for some time. I have been called in to cases of 
this kind where the patients were dying of diseased liver, with 
more or less dropsical swelling, who were said to be asthmatic. 
On the other hand, I have been consulted concerning patients 
sinking under dropsy from diseased heart, which was attributed 
to diseased liver ; an error more readily committed, in one in- 
stance, as the patient had returned with these symptoms from 
India. In all these cases auscultation was of the most valuable 
assistance to me in furnishing both positive and negative infor- 


tion, instead of attributing them to the true cause, 
morbid sensibility ; and, on that account, not only 
resorting to low diet and antiphlogistic medicines, 
but also to frequent bleeding by leeches or other- 
wise, which makes the patient more hysterical, and 
increases morbid sensibility. 

I have seen a young female who had been re- 
duced by diet and medicines, including salivation, 
for a cough and loss of voice, which was attributed 
by several practitioners, some of them of note, to 
chronic laryngitis, but which was nothing more than 
what I call an hysterical cough, and which gave way 
to tonic medicines and a generous diet, with exer- 
cise in the open air — the patient having been un- 
necessarily shut up for nearly two years from the 
air of heaven and human society. There is no more 
common error than that of excluding the air from 
patients who have that kind of cough called spas- 
modic asthma, especially those cases which depend 
on chronic (Laennec's dry) catarrh, and which I find 
are curable much more quickly provided the patient 
be sent out to take exercise in the open air even in 
winter. The lungs are provided by nature to admit 
cold air without irritation, but not over-heated air 
after being out in the cold : the most frequent 
cause of catarrh in winter is going to the fire and 
breathing hot air after having been out, the pre- 
judicial effect of which is exactly analogous to that 
of putting the hands to the fire after being out in 
the cold, which produces chilblain ; the same thing 
occasions a degree of chilblain in the fauces or 
larynx. The cold air is wrongfully accused, and 


the patient prevented from going into the cool air 
again, which would have relieved the symptoms. 

A medical friend of mine had a continued 
troublesome cough, causing anxiety on the ques- 
tion of consumption, and consulted me ; amongst 
other points, upon the necessity of using a close 
carriage instead of his cabriolet. I cured him by 
merely advising him to turn his back to the fire 
whenever he went into a patient's room, which 
was very frequently the case, he being in extensive 
practice ; and by recommending a more generous 
diet, as he had been living rather low through the 
fear of inflammation. 

On the other hand, to shew the value of aus- 
cultation where there was serious disease existing, 
I was consulted by a patient who had been ill about 
two months ; he had all the nosological symptoms 
of advanced consumption, — cough, expectoration 
yellowish white with a little blood, night-sweats, 
emaciation, some pain in the side on deep inspira- 
tion, &c. Thanks to Laennec, I was able to dis- 
cover immediately that it was not consumption, 
but hectic fever from neglected peripneumony ; 
and, notwithstanding the debility, I adopted pretty 
active treatment — free leeching of the side, and 
saline antimonial medicine, with milk and vegetable 
diet, which soon cured him.* 

* A gentleman engaged in an active business had been for 
many months affected occasionally with symptoms resembling 
what is called angina pectoris, a difficulty of breathing, or rather 
sense of distension in the chest, causing him to stop suddenly, 
from a feeling of distress and sometimes pain, and making him, 


Those cases called spasmodic asthma, which in 
reality depend on chronic catarrh, may be cured 
by tonic medicines combined with palliating expec- 
torants ; but this will not succeed unless the pa- 
tients, instead of being dieted and confined to the 
house, have every means taken, by animal food, 
fermented liquors, and exercise in the open air, to 
put them " in condition." 

I may here remark, that I totally disbelieve in 
the existence of spasmodic asthma as a disease of 
the muscular structure of the bronchial tubes (see 
Adv. 2d edit. p. xix.). I have never seen a case 

when it attacked him in a sitting posture, get up and walk about, 
from a painful restlessness. He had only occasionally a slight 
cough, looked well and florid, but was getting irritable and 
anxious, and could not sleep, from uneasiness in the region of the 
heart, which was increased by a deep inspiration, or by sneezing. 
The pulse ranged from 84 to 100, firm, rather hard ; the tongue 
pale ; he had no feverish languor ; and notwithstanding the above 
symptoms, and that he could not stoop to lift any thing from the 
floor without pain, he felt well and strong, he said, if it had not 
been for the bleeding, purging, and other antiphlogistic treatment 
most judiciously adopted by his medical attendant, who called 
me in to enforce compliance by his patient, who was a near rela- 
tion, and was rather surprised at my inculcating more " drench- 
ing," and a number of leeches to be applied at intervals of forty- 
eight hours for a week. This case was one of " latent" pleuro- 
peripneumony of the left lung (there was rhonchus crepitans, 
bronchophony, &c), which had continued in a chronic state from 
an acute attack six or eight months before : he was soon relieved 
by the active antiphlogistic treatment. These cases occur not 
unfrequently in hospital-practice, in artisans who have returned 
to their work too soon after acute attacks ; and are almost 
always cured by bleeding and sedatives, calomel, &c. ; often 
even after extensive dropsical symptoms have set in (see p. 51, 
line 15). 


which, sooner or later, could not be traced to or- 
ganic disease of some viscus, as the heart, liver, 
spinal cord, or lungs themselves ; such as emphy- 
sema, Laennec's chronic dry catarrh, &c. &c. Some 
of these latter cases, occurring in young or old 
persons, are curable ; many of those depending on 
organic disease of the heart in old persons can of 
course only be palliated. 

To return to the subject of the effect of the 
atmosphere on the lungs. The advantage of 
breathing warm air is very much over-rated. We 
uniformly see that real consumption (tubercular) 
runs its course rapidly in Italy, or any warmer cli- 
mate ; such, at least, is the result of my observa- 
tion.* A deception has arisen in consequence of 
persons not really consumptive, but affected with 
severe chronic catarrh, having been sent into warm 
climates, who, from the comparatively trifling na- 
ture of this disease, have returned cured, or at least 
not worse. In some of these cases, erroneously 
called phthisis, the progress of the disease is said 
to have been checked by the influence of the 
milder climate. This popular prejudice has still, 
however, a strong hold on the minds of men, and 
even auscultation has not yet corrected it. 

It is generally very unnecessary, and worse than 
useless, to send patients away from their friends, 
and often at an enormous inconvenience. If they 
are consumptive, they will thus die in exile ; and if 
not, they may be cured at home. Of the first it is 
unnecessary to give examples — there are abundant 
marble records in the neighbourhood of Leghorn, 

* I am confirmed in this opinion by the experience of Andral. 


in the West Indies and Madeira, &c. A case will 
explain more fully what I mean by the second. A 
young gentleman was condemned, by high medical 
authority, to banishment to Madeira, as " nothing 
else could save him ;" but to this some strong objec- 
tions existed. The first was love — he was on the point 
of being married ; the second, his engagements in 
a valuable business, which depended much on his 
personal superintendence : a reconsideration of his 
case was therefore moved for, and my opinion re- 
quested. I decided that it was mere chronic ca- 
tarrh in a relaxed constitution ; that some tonic, 
such as iron or bark, with animal food and fer- 
mented liquor, was alone necessary ; but, above 
all, exercise on horseback in the cool open air. 
Under this treatment he recovered within a month, 
and is now the father of a family. 

The case of another patient, who, after having 
been sent to the West Indies for incipient con- 
sumption, as it was called, had returned in good 
health, was triumphantly adduced to me as op- 
posed to my opinion (as the last-mentioned case 
would have been, had the patient exiled himself as 
at first recommended). On the following January, 
however, I was again consulted, in consequence, as 
it was said, of the consumptive symptoms having 
returned. I found the patient shut up in a warm 
room, dieted, and physicked, and waiting for a 
vessel, intending to sail again to a warm climate, 
at a great inconvenience as to family affairs, &c. I 
prescribed the same remedies as in the former case, 
and insisted upon walking exercise in the open air 
being commenced, even at that time of year. The 


patient was free from cough in about ten days, 
and has so continued five or six years. I must 
observe, that auscultation alone did not decide me 
in either of these cases : they had both been pre- 
viously seen by practised auscultators. Though a 
warm advocate for auscultation, I am aware that, 
besides the injurious and absurd affectation of some 
who are really practically ignorant of it pretending 
to understand its employment, there are others who 
place too much reliance on it for diagnosis, omit- 
ting the consideration of the collateral constitu- 
tional symptoms.* This is nearly as absurd as a 

* I have found more persons misled by impulsion of the 
heart than any other stethoscopic investigation. In many cases of 
phthisis I have been referred to, in consequence of the apparent 
hypertrophy of the heart, which depended merely upon the in- 
creased perceptibility of the heart's action (somewhat increased 
in reality by the progress of the disease) from the excessive thin- 
ness of the parietes of the chest. There are patients who have 
fits of palpitation of the heart from dyspepsia, &c., during which 
the impulsion is so great that it would mislead the practitioner, if 
he have not opportunity of ascertaining, that for weeks, during the 
intervals of the attacks, the action of the heart will be perfectly 
normal. (See p. 13, note.) 

An hysteric constitution in females and nervous in males will 
produce impulsion sufficient to deceive the practitioner in many 
instances, if, as is often done, the patient merely be shewn to him 
once for an opinion ; and medical men ought to be cautious of 
committing themselves. The best way of explaining this will be 
by a few examples. 

A young lady, set. fifteen, in a distant part of the kingdom, 
became affected with cough, violent action of the heart, and sub- 
sequently dropsical swellings. The physicians who saw her con- 
sidered her the subject of disease of the heart, and sent her up to 
head- quarters, London, for further advice. She was shewn to 
two highly talented physicians separately, who each confirmed 
the opinion, and gave little or no hopes of her recovery. Her 


Pasha requiring an English surgeon to prescribe 
for one of his wives, though he would allow him 
no more information respecting the case than that 

ordinary medical attendant called me in to see her. I found her 
with short breath, short cough, emaciated and dropsical, even in 
the upper extremities and face. There was very strong impulsion 
of the heart ; but I could not trace any acute rheumatism or other 
of the usual sources of hypertrophy of the heart at such an early 
age, and therefore discarded the idea, and set down the case as 
one of hysterical palpitation, with dropsy from debility; and 
prescribed tonics, such as chalybeates and quinine, in small quan- 
tities so as not to oppress the stomach, a generous diet, and an 
immediate resort to exercise, gestation in the open .air. Upon 
this plan she rapidly recovered, and has continued healthy for 
some years. 

A married lady was brought to me, not to ascertain the nature 
of her complaint, but to try if I could suggest any relief or remedy 
for hypertrophy of the heart, which another physician had declared 
it to be, but had not alleviated her symptoms. I ascertained, in 
the first instance, that she had been about a dozen years married, 
without having had any children ; she suffered from headaches, 
tormina, constipation, and other symptoms of hysteric indigestion, 
for which she was constantly resorting to purgatives, and of 
which the physician had rather prescribed an addition, instead of 
trying to wean her from the bad habit. With much difficulty I 
prevailed upon her to forego the temporary relief of purgatives, 
and to persevere with slight tonics, with terebinthinate medicines. 
Before long, the result was, that her health improved, she began 
to have a family, and lost the symptoms of hypertrophy. 

A young friend of mine, in consequence of a life of over-exer- 
tion in study, pleasure, business, and dissipation combined, brought 
on such violent action of the heart as would have induced most 
persons, from the mere impulsion, to have pronounced it hyper- 
trophy. I could see his dress move as he sat opposite to me at 
table. This state subsided without any medicine, by merely a 
more regular mode of living ; having lasted from about the age of 
nineteen to twenty-four. Now, at the age of thirty-five, his pulse 
and the action of the heart are perfectly normal. 

A gentleman, set. twenty-six, consulted me under similar cir- 


obtained from the one symptom of the pulse, the 
arm being thrust from behind a curtain. 

I must here make a few observations upon real 
consumption, and will point out those diagnostic 
symptoms which we are constantly and anxiously 
required to decide upon in the exercise of our pro- 
fession ; and at the same time that I shew the in- 
flexible character of the disease, and how slight is 
the chance of recovery from it, I wish to inculcate 
the possibility of temporary, and even of perma- 
nent cure, and to explain the rational mode of 
attempting it. In order to understand fully the 
symptoms of the stages of this formidable disease, 
it is necessary to bear in mind the condition of 
the lungs at different periods of the progress of 
tubercles, and the excavation of the lung subse- 

In speaking of consumption, I confine that term 
to the disease depending on the generation, growth, 
softening, and evacuation of tubercles ; and do not 
apply it to any of the sequelae of the common in- 
flammations — catarrh, peripneumony (p. 276, line 
18), and pleurisy, although they also may produce 

cumstances, but much out of condition, having been on low diet 
and taking active purgatives by the direction of a physician, who 
declared his disease hypertrophy of the heart. He was very nervous 
and low-spirited, and had neuralgic pain in the chest. I allowed 
him to take animal food and fermented liquors, and prescribed 
carbonate of iron, which quieted the action of the heart, and 
removed the other symptoms. 

These cases would of course have required different treatment, 
had the heart been really diseased, instead of being merely sympa- 
thetically disturbed in its function. 


hectic, and prove fatal. Many of the statements in 
works on the practice of medicine are incorrect ; I 
believe, for instance, that tubercular consumption 
has no connexion with common inflammation as a 
cause. We find in works on the practice of physic, 
the particles of dust in particular trades, as glass- 
cutting, set down as exciting causes of phthisis. 
Amongst the victims of those unhealthy trades, 
the ordinary proportion of true phthisis of course 
will occur, though not produced by them. And 
in some instances the dust may cause chronic 
catarrh, chronic peripneumonia, hectic, and pre- 
mature death, but not true tubercular consump- 

Tubercles are a peculiar morbid growth in the 
lungs, not produced by common inflammation, but 
arising like scrofula, if not identical with it, and 
which, so far from being produced by inflammation, 
do themselves produce inflammation ; but not till 
after they have grown to some size, though inflam- 
mation may incidentally occur simultaneously with 
their generation. The little light-coloured grains, 
not larger than the head of a pin, which constitute 
the first state, or germination, of the tubercles in 
the lungs, have also the names of miliary tubercles, 
from their resemblance to millet -seed. In this 
state it is my opinion that they may remain many 
years, without producing any symptom whatever : 
the person may or may not have a cough at the 
same time from catarrhal affection, or sympathetic 
irritation ; but instances occur of their being in the 
lungs without producing cough, though we have 
very seldom an opportunity of seeing this con- 


firmed ; unless sometimes, when a person dies in 
consequence of an accident, or some acute disease, 
and we discover young tubercles in the lungs. We 
may also observe miliary tubercles in lungs which 
contain older and riper tubercles, as it is their 
nature to come on in successive crops ; so that 
we occasionally find young ones in a patient 
who has died in consequence of those previously 

I may refer to the case of a young female in 
the hospital, who, whilst under treatment for araen- 
orrhcea, went out on leave of absence on an incle- 
ment day, and got an attack of peritonitis, of which 
she speedily died. She had no cough, though it is 
so common a complaint with amenorrhceal females ; 
yet on examination of the viscera there were found 
a great many miliary tubercles in one lung. These 
miliary tubercles, except when the lung is injected 
with red, are more easily felt than seen, as they 
are of a semi-transparent grey colour, and when 
cut into, or bruised with the nail, have very much 
the appearance of the lymphatic ganglia ; they 
grow larger by a deposition of a whitish substance 
resembling coagulated lymph, only denser, which 
seems to be deposited within them, rather than 
converted from them ; and this substance after- 
wards softens to the consistence of curd, not dif- 
fering in appearance from what is always formed in 
strumous enlargements. Whilst this white sub- 
stance is firm, the tubercle is called crude or un- 
ripe, presenting a firm white appearance when cut 
into ; such being the second stage. The term 
maturation is applied to the third stage, from its 


having been supposed to be suppuration ; as the 
softening of the tubercles has been erroneously 
considered a maturation or ripening of abscesses. 
But this melted-down tubercular matter is different 
from pus, which is formed fluid in the first instance, 
as may be seen every day on the surface of granu- 
lating wounds or ulcers. The melting down of 
the tubercles is the effort of nature towards a cure. 
By their thus becoming liquid, the resulting creamy 
matter makes its way into the bronchial tubes by 
an ulcerative process, during which, or, more pro- 
perly, during the existence of that degree of inflam- 
mation which takes place previous to the breaking, 
as well as whilst they are emptying, there is hectic 
fever; and according as the tubercles are evacu- 
ated, a number of small cavities, causing a honey- 
combed appearance, are left in the lung ; and as 
the tubercles are often in masses or clusters, large 
pouches will sometimes remain after all the white 
matter is expectorated. Provided there have been 
but few tubercles in the first instance, a new mem- 
brane or lining invests the resulting cavities, and 
the patient may live on : this result is a real reco- 
very from actual phthisis, which has by some been 
thought impossible. But the disease will generally 
return sooner or later, unless the individual die of 
other disease. 

The nature of tubercles is not yet decided. I 
am of opinion that they are a strumous disease of 
the minute lymphatics of the lungs, growing like 
other tumours by the addition ofcoagulable lymph, 
which assumes various grades of organisation, and 
follows the course I have just described. The 


analogy of the morbid process is in favour of this, 
and also of the most successful treatment in the 
very few cases which recover after the tubercles 
have ripened. Considering this simple statement 
of the disease, one might be surprised that more 
do not recover ; but we must recollect that these 
tubercular tumours being within the lungs, must, 
during their progress, induce, and be complicated 
with, more or less peripneumony, pleurisy, and 
bronchitis ; besides the diminution of the pulmo- 
nary tissue so necessary to life, and the hectic 
wear of the constitution. 

In addition to the distinct tubercles in a crude 
state, a mass or several masses of this crude tuber- 
cular matter is sometimes found, to which Laennec 
gives the name of tubercular infiltration, I believe 
it to be exactly similar to the other — with a deposit 
of lymph produced by the irritation of the tubercles, 
coalescing into a mass, according to the circum- 
stance of greater or less inflammatory action. A 
very similar-looking deposit takes place in cases 
of peripneumony, to which Laennec has given the 
name of purulent infiltration, but which is by no 
means pus, but coagulable lymph ; solid at first, and 
which afterwards melts down, like the tubercular 
deposit; the tubercular being the firmer of the two, 
perhaps from its more gradual formation. 

Now, the tubercles at commencement do not 
necessarily produce any symptoms (as shewn in 
the young woman's case above mentioned, p. 284), 
any more than a chain of strumous knots on the 
lymphatics, which may frequently be felt in the 
side of the neck, but which produce no uneasiness, 


and are often reabsorbed without any remedy being 
used. We have no proof whatever that tubercles 
in the lungs are not reabsorbed, and I rather sus- 
pect they sometimes are ; we can never be certain, 
as the difficulty that we have in ascertaining their 
existence in the early stage is so great, unless they 
be in such number that there remains little hope 
of recovery. Yet the progress of auscultation has 
been such, that we may hope for still further ad- 
dition to our means of diagnosis ; and the more 
thorough knowledge we have of the nature of the 
disease, the better we shall be able to combat it. 
Hitherto the application of remedies in phthisis 
has been in many cases quite empirical, often inert, 
and sometimes mischievously active. The student 
must bear in mind that it is a disease of tremen- 
dous destructiveness, and that there are but few 
cases within the reach of art ; but he should recol- 
lect that some are curable, at least for a time ; 
otherwise he will lose that persevering energy 
which it is the duty of every medical man to exert 
as long as life remains : I do not say, as long as 
there is hope, for many patients recover, from 
various diseases, after all hopes have been relin- 

Whoever understands theretatment of strumous 
cases has the groundwork of the treatment of phthi- 
sis, modifying that by calculating the nature of the 
organ in which the tubercular tumours are formed, 
and throughout making every effort to support the 
strength, not merely to preserve the vital powers, 
but for the purpose of promoting the kindly healing 
of the sores ; for we have abundant opportunities 


of seeing, in surgical cases, how rapidly strumous 
and other ulcers get worse as the patient becomes 
weaker. Hence one of the great difficulties in 
phthisis is, that the presence of the tubercles con- 
stantly brings on inflammation, which takes the 
form of peripneumony, or pleurisy, and requires 
antiphlogistic treatment ; while the risk is, that in 
reducing the acute inflammation we reduce the 
power of the constitution, and so increase the 
chronic or strumoid disease. Here we have an 
explanation of the benefit experienced by some 
from the use of digitalis, or hydrocyanic acid, which 
keeps down the pulse and the acute inflammation, 
without wasting the vital fluid, or depressing the 
system, except in cases where it disagrees with the 
stomach, and then of course it does mischief by 
weakening. And because digitalis had proved use- 
ful, it has been recommended and used empirically, 
that is, indiscriminately. Being, however, employed 
in so fatal a disease, it of course lost its character, 
except in the hands of those practitioners who 
could understand in what states it was occasionally 
beneficial, and would limit its use to them; knowing 
that, in the cases of phthisis with a feeble pulse and 
no tendency to acute inflammatory action, it could 
do nought but harm. Again, the constant repetition 
of emetics in phthisis, as well as in abscesses, has 
done good on a similar principle, by checking the 
deposition of new matter, and facilitating the re- 
moval of old ; as elaterium is useful in dropsy by 
its emetic as well as purgative properties. But the 
repetition of emetics is so distressing, and the 
chances of curing phthisis are so doubtful, that few 


persons now prescribe this mode of treatment, 
which was at one time much praised and resorted 
to in this disease, as well as by surgeons for the 
removal of abscesses. 

Some years ago a gentleman of the name of 
Stewart adopted a rational mode of treatment, with 
which he had considerable success ; but because 
he could not work miracles, his plan was unjustly 
depreciated. His method was entirely tonic, and 
especially the cautious use of cold and tepid ablu- 
tions of the skin — a modification of cold bathing; 
a remedy which is found so uniformly beneficial 
in promoting the resolution of strumous tumours. 
Some patients with phthisical symptoms recovered / 
strength for a time under his directions. Others 
had a recurrence of their symptoms, and died ; 
but this should not be held an argument against 
the propriety of his treatment, which brought the 
patient through one crop of tubercles, though a 
second or a third crop proved fatal. The hydro- 
cyanic acid, again, has been of great use in some 
cases ; but not being able to effect impossibilities, 
it has shared the fate of digitalis and of Mr. 
Stewart's plan. 

One great advantage of auscultation is that of 
enabling us to decide whether any cases of con- 
sumption are cured or not. Previous to its dis- 
covery, if a case recovered, a doubt always existed 
whether the patient had been really consumptive, 
as in Stewart's cases ; whilst all who died were put 
to the account of consumption, without any reserve. 
I may here recapitulate a few of the auscultatory 
observations made in practice. If few miliary or 



even crude tubercles be deposited in the lung, no 
evidence is afforded by auscultation or percussion ; 
if there are many, or tubercular infiltration has 
taken place (and we may almost always expect to 
find them near the clavicles), there is diminution 
of respiratory murmur ; but from the solidification 
more or less bronchial respiration or bronchophony, 
and some diminution of sound on percussion, occur. 
Whereas, if the patient's cough be produced by ca- 
tarrh, the sound on percussion will not be dull, and 
there will not be bronchophony ; and if the mur- 
mur be diminished by emphysema, the sound from 
percussion will, on the contrary, be extra loud. In 
the progress of the disease there is no alteration in 
these auscultatory signs, except augmentation, until 
the tubercular matter, having ripened, begins to 
make its way into the spongy texture of the lungs 
and bronchia, when a kind of crepitation is heard, 
being a mixture of rhonchus mucosus with the 
rhonchus crepitans, or what Laennec calls subcre- 
pitans, and partaking more of the pure crepitation 
in proportion as, about this time, the lungs may 
become in a peripneumonic state just round the 
tubercles, or the rhonchus mucosus be mixed up 
with cedematous crepitation when the consumption 
has brought on dropsical symptoms; besides which 
we find occasional admixture of rhonchus sonorus 
gravis, or sibilans, which must not be confounded 
with the diagnostic signs, but which we need not 
here analyse, as that may be done with facility and 
advantage at the bed-side. When the sounds can- 
not be satisfactorily heard during respiration, the 
patient must be made to cough, so as to remove 


any mucus which may be obstructing the tubes, 
and preventing the real state from being heard. 
After the crepitation has lasted some time, we 
begin to have new sounds, according as the cysts 
of the tubercles get cleared out : when quite 
empty, cavernous respiration and pectoriloquy may 
be detected ; when they contain some soft tuber- 
cular matter, and pus or mucus, we hear cavernous 
guggling rhonchus. The sound from percussion at 
that period alters, becoming louder again, on ac- 
count of the hollowness from the excavations. 

Pectoriloquy is a certain evidence of the exist- 
ence of an excavation; indeed a cavity not larger 
than a nutmeg, or even less, produces pectoriloquy 
distinctly. In one instance I had a patient with 
aneurism of the aorta, in whom, during examination 
of the chest, pectoriloquy was observed in one spot 
only, which was between the scapula and spine, and 
which sometimes ceased to be discoverable for a 
day. After death this was accounted for; it was 
found that disease of a vertebra, close to the head 
of a rib, had caused a small abscess, which, in- 
stead of pointing externally, had made its way into 
the lung, through which the pus was evacuated. 
This cyst, not so large as a nutmeg, gave pecto- 
riloquy when empty ; but when full of pus, as 
when he had been lying quiet, of course emitted 
no sound. 

I must observe, that nosological symptoms are 
not sufficient to establish the existence of tubercular 
consumption ; the whole train of symptoms may 
occur as the production of an ordinary cause (p. 276, 
1. 16); such as catching cold from wet feet, produc- 


ing peripneumony or pleurisy in the first instance ; 
the sequelae of either are, not unfrequently, hectic, 
with cough and expectoration, the latter of which 
might be so similar to phthisis, that if it were 
alone considered, it would be presumptive evi- 
dence of phthisis. Expectoration of blood would 
be by no means inconsistent with the supposition of 
the disease being only pleuritic in the first instance; 
and I must here take the opportunity of observ- 
ing, that though there are not many cases of 
phthisis in which there is not some expectoration 
of blood at some period, still that many cases of 
haemoptysis occur without being connected with 
tubercular disease, and more especially in females. 
The heightened colour of the cheeks may not be 
found circumscribed, which is worthy of attention, 
shewing how perfect an intermission there may 
be, in the forenoon, though the hectic be fully 
formed, so as to produce hot dry skin and circum- 
scribed hectic flush in the evening; followed by 
night -sweats, or rather morning - sweats, for the 
phthisical patient is generally hot, dry, and restless 
till four or five o'clock, when a sleep comes on, 
which soon terminates in an uncomfortable state 
of perspiration. The patient in phthisis has usu- 
ally an aphthous state of the mouth, the fauces 
being inclined to be sore, as well as the back of the 
tongue, with a whitish pellicle, the tongue florid 
and glazed, as if skinned ; but neither this thrush 
in the mouth nor night -sweats are diagnostic of 
tubercles, they being met with in hectic from any 
cause — dysentery, for instance, or from abscess 
in the liver or groin, psoas abscess, &c. But if, 


added to the preceding symptoms, we have the 
signs of true phthisis derived from auscultation, all 
doubt will be removed, and we have only to trust 
to the means of supporting the strength and allay- 
ing morbid sensibility. 

In various parts of both lungs, in cases of phthisis, 
there will generally be found tubercles in different 
stages, explanatory of the symptoms noticed during 
lifetime; and also ulcerated appearances in the in- 
testines at the termination of the ilium and about 
the sigmoid flexure of the colon, explanatory of 
the distressing diarrhoea which constantly occurs in 
these cases in the latter stages. 

The thrush in the mouth in phthisis is gene- 
rally coeval with, and indicative of, an ulcerated, 
aphthous, or thrushy state of the bowels ; but we 
must not imagine that aphthae, especially in young 
persons, are always accompanied with ulceration 
of the bowels ; for children have thrush very fre- 
quently when debilitated by diseases, such as from 
teething or worms, from which they rapidly recover 
when the cause is removed. 

Before we possessed the means of diagnosis 
established by Laennec, some cases used to be 
thought phthisis laryngea, on account of the loss 
of voice and incessant " laryngeal" cough, afford- 
ing false hopes that counter-irritation on the throat, 
&c. might effect a cure. Formerly many a case of 
phthisis used to get the name of a liver-cough — 
that is, when accompanied by a pain in the right 
hypochondrium, costiveness, and indigestion ; but 
now the auscultatory symptoms tell too truly the 
state of the lungs. 



In many cases of phthisis, I may repeat, there 
occurs the superaddition of peripneumony, pleu- 
risy, haemoptysis, or catarrh, or complications with 
disease of other viscera ; and often dropsy comes 
on at the last, and hastens the fatal termination, 
or that pleuritic and purulent effusion into the chest 
which Laennec calls empyema. When there is hae- 
moptysis, peripneumony, or pleurisy, or any com- 
plication requiring antiphlogistic treatment, we 
must recollect the analogy between the phthisical 
and strumous constitutions, and save the strength 
of the patient as much as possible. I would advise 
the young practitioner not to bleed patients beyond 
what is absolutely necessary to check inflammations 
in any case, but more especially in those superad- 
ditions which occur during the progress of tuber- 
cular phthisis. In peripneumonia or pleuritis, with 
a consumptive habit, we must avoid the risk of 
knocking down the constitution, if possible; but 
I confess we are sometimes placed between two 
evils, and must then choose the lesser, as well as 
we can judge. 

One thing of which I am convinced is, that the 
true principle of treating consumption is to support 
the patient's strength to the utmost;* and that 

* Many years ago a young married lady, who had two / 
children, came under my care with all the symptoms of confirmed 
consumption, cough and muco-purulent expectoration. She had 
occasionally expectorated a little blood ; there were ni°-ht-sweats 
and colliquative diarrhoea. I supported her strength with animal 
food, and some fermented liquor, whenever her pulse could bear 
it ; gentle exercise in the open air, and free admission of air into 
her rooms. I restrained the diarrhoea by catechu, logwood, and 
sometimes opiates ; sometimes applied half-a-dozen leeches,' and 


though occasional complications may call for anti- 
phlogistic treatment, tubercular disease by itself 
does not. I must again caution young practi- 
tioners against shutting up phthisical patients in 
warm rooms. I am satisfied that the want of ex- 
ercise induces a languor which makes them wear 
out faster than if permitted to ride or walk, accord- 
ing to their strength, in the open air. At every 
exacerbation of their complaint, phthisical patients 
say they have " caught fresh cold ; " but the same 
thing occurs when the experiment is tried of keep- 
ing them in rooms graduated by a thermometer. 
A mild climate is palliative, by permitting more free 
exercise in the open air : but when we look at the 
specimens in our museums, we may judge whether 
a warm climate could regenerate such lungs. 

To return from this long digression upon 

blisters, and gave digitalis for a few days when there was appear- 
ance of acute inflammation ; sometimes gave bark and soda ; 
sometimes quinine with diluted sulphuric acid, which restrained 
the sweats. Beyond my hopes, she got well, and continued so 
for about five years, having one child more in that time. I think 
that during the attack she had expectorated a crop of tubercles, but 
I cannot be certain, as I had not then practised auscultation. How- 
ever, after the five years, she had a renewal of all the symptoms ; 
and I know that she then had cavities in the lungs, as 1 ascer- 
tained by auscultation that there was crepitation, pectoriloquy, 
and cavernous respiration. From this she recovered again, in 
about a year ; and when she regained her strength had another 
child. Within two years from her second recovery she had ano- 
ther return of the same symptoms, and died, — the lungs, upon 
examination, being full of large cavities. The process of utero- 
gestation is said to suspend the progress of phthisis ; but in this 
case the period occupied by one pregnancy bears a small proportion 
to the interval between the first and second attack (p. 289, 1. 27). 


phthisis, we may consider chronic diarrhoea to be, 
in fact, frequently a catarrhal state of the mucous 
membrane of the intestinal canal, and requiring to 
be treated on the same principles as explained 
pp. 271, 272, whether it arise from mere sympa- 
thetic morbid sensibility, as in hysteric females, or 
from chronic inflammation of the membrane itself, 
or congestion, or mere loss of tone combined with 
indigestion, in which haematoxylum and other as- 
tringents must be substituted for expectorants. In 
the diarrhoea which occurs from the necessary ad- 
ministration of mercurials, haematoxylum will be 
found a most valuable remedy, with or without 
opiates ; and also in the chronic diarrhoea of gouty 
habits, &c. In the diarrhoea of children it is most 
valuable, and possesses the advantage, for them, of 
having no disagreeable taste. 

The consideration of the internal rete mucosum 
naturally leads me to say a few words concerning 
the external rete mucosum, as the seat of cuta- 
neous diseases, the cure of which has been much 
retarded by the well-intended labours of the noso- 
logists. Their time has been wasted in making dis- 
tinctions between diseases which are as like one 
another as one horse is to another ; or resembling 
each other as much as a horse does a mule, or an 
ass a zebra — the species of each genus of disease 
being curable by the same means ; so that, in fact, 
the true service to medicine would have been to 
have shewn wherein the different varieties resembled 
each other in essential points, so as to cure them 
on principle. 



The first great distinction we have to establish 
in cutaneous diseases is between the contagious 
and non-contagious. In the former class we can 
include with certainty two only — the itch and 
porrigo capitis (the ring-worm of the scalp, or 
scald head). Whatever other chronic eruption 
the young practitioner is consulted about, he may 
at once answer for its not being contagious ; but 
it will require a little experience to enable him to 
distinguish the various forms which the itch, for 
example, assumes. To assist him, however, he may 
recollect one unaccountable peculiarity which it ex- 
hibits, of never affecting the face. The itch is some- 
times papular, sometimes pustular, sometimes vesi- 
cular, sometimes scaly, though unequivocally the 
same identical disease ; in other words, according 
to the state of the constitution, the same irritating 
cause — recently demonstrated to be a peculiar in- 
sect {acarus scabiei) — may produce a disease resem- 
bling prurigo, eczema, impetigo, ecthyma, herpes, 
or psoriasis ; the itch, in fact, communicated from 
a patient who has it in the pustular form may pro- 
duce it in another person in the vesicular or papular 
state ; and from analogy I infer, that the various 
cutaneous eruptions are but degrees of one state — 
a morbid sensibility and loss of power in the capil- 
laries of the rete mucosum, assuming various forms 
according to the age and constitution of the patient; 
as we see morbid sensibility propagated from the 
gums produces in infants strophulus or porrigo lar- 
valis, diseases never seen in adults, or if they occur, 
are in them called prurigo, lichen, or herpes, or 
something equivalent, distinguishable certainly, be- 


cause the difference of age modifies the appear- 
ance, though not the quality. 

I believe it will be found perfectly useless, as 
far as treatment is concerned, to make any further 
division of chronic cutaneous diseases than into the 
papular, scaly, pustular, and vesicular. I really 
see no use in the interminable hair-splitting dis- 
tinctions made by authors, from Willan down to 
the present time ; and they are most appalling to 
the unhappy student, leading to vain repetitions in 
description of remedies, and an empiricism which 
excludes or confounds the principles of treat- 

The first or lowest degree of derangement is 
papular, or simple itching, which is sometimes not 
even evidently papular ; in which the nerves evince 
morbid sensibility only, the first degree of debility, 
leading to congestion of the capillaries in those 

Next comes the thickening, i. e. relaxation 
and sponginess of the rete mucosum in various 
points, the relaxation being sufficient to cause a 
slight loosening of the cuticle, which adheres in 


The third is the pustular, when the relaxation 
has gone the length of some minute loss of sub- 
stance, which the surrounding healthy capillaries 
set about restoring by granulation and suppuration 
of pustules. 

The fourth might be thought by some to be a 
minor degree, because apparently more simple — the 
mere separation of the cuticle in the form of vesicle; 
but, on the contrary, this is a higher, being a more 


rapid inflammation ; and, moreover, we see ana- 
logically that these vesications take place in con- 
nexion with the erysipelatous state of disease which 
evinces loss of power of the constitution. Vesicular 
ecthyma takes place in weak strumous patients ; 
mercurial vesicular disease, when the constitution is 
suffering from the mineral; pemphigus and vesi- 
cating patches of purpura or scurvy, when the con- 
stitution is in the worst state. 

The co-existence of disease of the lining of the 
intestinal canal and skin, or of the internal and 
external rete mucosum, has been universally ob- 
served and acknowledged. This connexion T attri- 
bute to the whole being supplied by the ganglionic 
system of nerves, whereby an impression is pro- 
duced on the skin through the prima? vise, as when 
cold water drank during perspiration produces scaly 
eruption on the skin, or when, vice versa, applied 
to the skin, it produces pain in the stomach and 
bowels and diarrhoea, and as iron or arsenic taken 
into the stomach cures cutaneous eruptions, or a 
warm bath relieves diarrhoea. 

I defy any person to apply remedies for cuta- 
neous diseases with any degree of precision by the 
directions of Willan or any of his followers. But 
enough has been said in the preceding pages to 
guide to the application of remedies on principle 
to these chronic inflammations and their conse- 
quences. In the first place, tonics, such as iron, 
mercury, and arsenic, cure in two ways — by their 
direct effect upon the vessels of the skin when 
circulated to them, and by their effect -upon the 
primae viae in giving tone : we must not, however, 



produce salivation by the mercury, nor inflamma- 
tion of the bowels by too free use or abuse of 
mercury or arsenic. Iron, again, injudiciously 
applied, will rather retard digestion, of which it is 
the greatest promoter in proper doses, which doses 
are relative, as has been already shewn. Com- 
pound decoction of sarsaparilla, with the mezereon 
and decoction of dulcamara, are most valuable 
remedies ; but if the stomach and bowels be op- 
pressed by them, they do no good. I have shewn 
(p. 190, note,) how remedies sometimes fail from 
being too energetic. In cases of psoriasis, in which 
the usual routine of " specifics" had been tried by 
various practitioners unavailingly, because too freely 
applied, seeing that the patients were of a very 
delicate though not unsound constitution, with 
weak digestion though not want of appetite, I have 
given the mildest tonic, the sulphuric-acid lemonade, 
which has rapidly cured the previously intractable 

Antimony circulated to the cutaneous vessels is 
most valuable, but we are told it often fails— we 
are not told why : the reason is, that the cutaneous 
eruptions not being acute diseases, not febrile, 
there is little tolerance of antimony, and therefore 
the common doses are often oppressive. It cannot 
be too often repeated, that persons frequently give 
much too large doses of remedies in chronic dis- 
eases, and thereby fail. And again ; the sedative 
antimony cannot cure the eruptions of broken- 
down constitutions, which require tonics and full 
diet; and in such cases, as the primae vire are 
weak, it is often a difficult matter to get them to 


profit by the tonics and diet; and therefore we 
may be obliged to begin by the mildest, such as 
hsematoxylum as a tonic, and milk, with perhaps a 
little brandy, as nourishment ; or the sulphuric- 
acid lemonade, with animal broths and jellies, and 
farinaceous diet. Warm and vapour baths are 
commonly useful by softening the scaly eruptions ; 
and at the same time the warm bath is a powerful 
means of soothing the primae vise, and restoring 
them to tone and digestive power ; but in some of 
the papular eruptions the heat often rather in- 
creases the tingling of the skin. 

Alkaline washes are highly useful to excite 
the relaxed vessels of the skin ; but they require 
great varieties of dilution, according to the sensi- 
bility of the parts. The same may be said of 
mineral acid washes ; the alkaline washes are 
generally preferable, as more cleansing. The dul- 
camara has a powerful effect externally as well 
as internally. In fine, the successful treatment of 
skin - diseases depends upon no "specifics," but a 
judicious application of medicines, air, exercise, 
bathing, and diet, on account of the state of the 
digestive organs : we may use mercury as a tonic 
to them and the capillaries, being mindful not to 
salivate, not to oppress by over-doses of antimony, 
hydriodate of potass, &c. ; and in chronic cases, 
when remedies fail, to recollect that they may 
have been used too freely. 

Some cases of psoriasis, &c. are accompanied 
by, or depend upon, a congested sub-inflammatory 
state of the mucous membrane of the stomach, 
evinced, besides the presence of general signs of 


indigestion, by occasional nausea, and a foul or too 
red tongue, or both together, a hard pulse, pre- 
cordial uneasiness, or palpitation. In these cases 
the emetic substances, such as ipecacuanha and col- 
chicum, in doses just short of nauseating, and con- 
tinued for some time, are highly useful, combined 
or alternated with tonics, logwood, prussic acid, &c. ; 
in such cases the preparations of iron are often not 
so useful as acetate of lead, being less sedative. Tur- 
pentine is an excellent tonic, having the advantage 
of being laxative, and promoting the secretion of 
the kidneys : a very useful combination is, tur- 
pentine, quinine, and subcarbonate of soda, espe- 
cially for strumous constitutions ; and to make a 
mass for pills, rhubarb, aloes, ginger, cascarilla, 
ipecacuanha, colchicum, or liquorice-root, &c, may 
be added, according to whether there be any colla- 
teral indication or not. 

In the foregoing pages I have endeavoured to 
lay down general principles, which may apply to 
the particular cases of disease as they occur — these 
principles being deduced from physiology ; and for 
the explanation of pathological phenomena I have 
referred to the action of capillaries and nerves- 
nerves and capillaries together, not artificially sepa- 
rated, but as they exist in nature — ramifying with 
and supporting each other throughout ; for by their 
combined action upon the blood sent to them by 
the heart, they produce the phenomena of health 
— in their deranged actions they originate disease. 
I have also tried to explain the nature of remedies; 
and I have only to add that, in applying them, 


though not a moment should ever be lost, we must 
have patience in allowing them to act ; and that, 
though inert practice is mischievous, the safety of 
the patient depends upon ne quid nimis. 



23 Great New Street, Fecter Lane. 



Abscess, 140, &c. 

prevented, 172, &c. 

Absorption, 7, 264, &c. 

Ague, 228, &c. 

Ammonia, 158, &c. 

Aphthae, 292-3, &c. 

Apoplexy, 222, &c. 

Arterial action, 9, 15, 22, 25, 27, 55, et passim. 

" Asthma," 274, 277, &c. 

Astringents, 64 et seq., &c. 


Blood-letting, passim. 



Capillaries, 4, 25, 27, et passim. 
Carbuncle, 141, &c. 
Catarrh, 271, &c. 
Cholera, 240, &c. 
Circulation, 3, 9 to 15, &c. 
Climate, warm, 278, 293, &c. 
Club-foot, 199, &c. 
Cold, 170, 189, &c. 
Congestion, 26, &c. 
Constringents, 64 et seq., &c. 
Consumption, 282, &c. 
simulated, 278, &c. 

Cough, 272, &c. 
Cutaneous, 296, &c. 


Delirium tremens, 207, &c. 
Determination, 31, &c. 
Diet, 108, &c. 
Digitalis, 80, 115, 288, &c. 
Dropsy, 262, &c. 



Elaterium, 265, &c. 
Emphysema, 290, &c. 
Epilepsy, 204, &c. 
Erysipelas, 45, 255, 260, &c. 
Erysipelatous, 142, &c. 
Eschar, 50, &c. 

Fever, 149, et seq., &c. 
Faeces, appearance of, 189, &c. 


Gangrene, 50, &c. 
Granulation, 42, &c. 
Gravel, 129, &c. 



Haemoptysis, 273, 292, &c. 

Haemorrhage, 269, &c. 

Heart impulsion, 12, &c. 

sounds (Advertisement to Second Edition), p. xxi. 

Heat, animal, 20, &c. 
Hydrocyanic acid, 116, &c. 
Hysteria, 147, 273, &c. 


Inanition, 84, &c. 

Inflammation, 23, 33, 33, et passim. 

, " adhesive," 53, &c. 

, acute, 57, &c. 

softening, 57, &c 

, chronic, 58, &c. 

, morbid, 58, &c. 

Intention, first, 41, &c. 
Iodine, 69, &c. 
Irritation, 32, &c. 

morbid sensibility, (Advertisement to Third Edition), 

p. viii., 32, &c. 




Liver cough, 274, 293, &c. 
Logwood, 191, &c. 
Lymph, 47, &c. 


Membranes, " false," 47, &c. 
Meningitis, 237, note, &c. 
Mercury, 68, 98, &c. 
Mortification, 50, &c. 


Narcotics, 86, &c. 

Nerves, (Advertisement to Second Edition), p. xviii., 16, et 

Neuralgia, 194, &c. 
Neuroses 194 et seq., &c. 
Nutrition, 5, &c. 


Opium, 87, et passim. 



Paralysis, 222, &c. 
Pectoriloquy, 291, &c. 
Petechial synocha, 150, &c. 
Phlegmonous, 142, &c. 
Phthisis, 282 et seq., &c. 

laryngea, 293, &c. 

Plethora, 84, &c. 

Pressure, 64, &c. 

" Proud flesh," 43, &c. 

Pulse, 230, &c. 

Pus, 42, &c. 

Pyrexia, 149 et seq., &c. 



Reparatory process, 45 et seq., &c. 
Resolution, 33, &c. 
Rheumatism, 240, &c. 
Rigors, 140, &c. 



Scarlatina, 184, &c. 
Secretion, 33, &c. 
Sedatives, 80, &c. 
Sensibility, 18, &c. 

morbid, 45, 117, et passim. 

Sleep, 176, &c. 

Specifics, 72, &c. 
Sphacelus, 50, &c. 
Spleen, 32 note, &c. 
Stimulants, 77, &c. /52 

in fever, 175, 183, &c. 

Support, 44, &c. 

" Sympathetically," 123, 146, &c. 
Synocha, 154, &c. 

petechialis, 150, &c. 

Tetanus, 187, 209, &c. 
Tic Douloureux, 74, &c. 
Tongue, 217, &c. V 
Tonics, 92, &c. 
Tubercles, 283, &c. 
Tumours, 61, &c. 
Typhus, 154, &c. 


Ulceration, 48-52, &c. 



Vascular action, 55, &c. 
Venesection, substitute for, 178, &c. 


Water-dressing, 43, &c. 


Y. Z. 



23 (heat New Street, Fetter Lane. 























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" It is a plain, judicious and practical treatise. It gives the pith of what is known, and of what it 
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The Following List comprises a Part of the Plates which are finely executed by Canton, and 

carefully coloured. 

Proper and Injurious Modes of Examining the Eye distinguished. 

Acute Inflammation of the Conjunctiva. Aphthous or Pustular Inflammation of the 

Conjunctiva. Chronic Aphthous Inflammation of the Conjunctiva. 
Inflammation of the Cornea as seen in Strumous Ophthalmia. Pannus or Vascular 

Granular State of the Conjunctiva of the upper lid, with the first effects of its pressure 

upon the globe. 
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ditto. Fungus Haematodes in its earliest stage. 
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Acute diffused Inflammation of the Sclerotic. Haze of the Cornea, with Inflammation of 

the Iris. 
Chronic Sclerotidis. Appearances of Sclerotic and Conjunctival Inflammation contrasted. 
Fungus Haematodes of the Globe of twelve years standing — ditto at its termination after 

sixteen years — appearance of the Orbit on removal of the tumour after Death. 
Melanosis affecting the Globe and Lids. 
Sections of Malignant Diseases, illustrating Hodgson's discovery of the formation of serous 

Cysts as the origin of Cancerous, Fungoid, and other Diseases. 
Staphyloma Racemosum. Glaucoma — often mistaken for Cataract. 
Purulent Ophthalmia. Inflammatory Chemosis. 
Transparent depression of the Ulcer indicating Ulcer of the Cornea. 
True Pterygium distinguished from Pterygium Pingue. 

Capsulo Lenticular Cataract — Soft Cataract — Central and Opaque Capsular Cataract. 
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for Depression. 
Operation for Artificial Pupil. 
Instruments used in different Operations on the Eye. 





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" To the general Practitioner as well as the professed Dentist, we can conscientiously recommend 
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The Structure, Organization, and Vitality, of the Teeth. 

Number, Arrangement, and Uses of the Temporary and Adult Teeth. 

Articulation of the Teeth. 

Of Mastication and the Parts concerned therein. 

Formation and Progress of the Temporary and Permanent Teeth. 

Diseases resulting from the irritation of Dentition. 

On temporary irregularity and its prevention. Permanent irregularity. 

Supernumerary Teeth. On the Osseous union of Teeth. 

On the supposed occurrence of a third set of Teeth. &c. &c. &c. 


On Dental Gangrene (commonly called Caries) — Its origin and progress — Its proxi- 
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On total Necrosis — Abscess in the Bony Structure — Exostosis of the Teeth. 

Injuries produced by Mechanical Violence. 

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On Salivary Calculus — Its formation and effects — Means of prevention and removal. 

Diseases of the internal Membrane. 

Diseases of the Gums and Alveolar Processes. 

Effects of Mercury on the Teeth, Gums, &c. 

Diseases of the Antrum Maxillare. 

On Extraction of the Teeth, and accidents accompanying, or following it. 

Neuralgia, and Nervous Affections connected with the Teeth. 


The Formation, Growth, and Development of the Teeth in the Foetus and Adult. 

Natural and Magnified Sections of the Teeth. 

Production of the permanent Teeth, and their connexion with the temporary ones. 

The upper and lower Alveoli after removal of the Teeth. 

The upper and lower Teeth, with their Articulations. 

Gangrene. Abscess. Fungous Growth, &c, of the Teeth. 

Instruments. — &c, &c, &c. 





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Anatomy of the Ear — External Ear, Tympanum, Labyrinth, Nerves of the Ear. 

Physiology of Hearing. Sound. Influence of Sound upon the Ear. Influence of the 
External Ear. Influence of the Membrane of the Tympanum. Influence of the 
Ossicula. Influence of Air on the Tympanum. Influence of the Labyrinth. Influence 
of the Nerves. 

Of the Abnormal Condition of the Ear — Development and Malformations. 

Of the Diseases of the Ear. — Acute Otitis. External Acute Otitis. Inflammation 
of the Membrana Tympani. Internal Otitis. Inflammation of .the Labyrinth. 

Chronic Diseases. External Otitis. Inflammation of the Auricle. Chronic Diseases of 
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Nervous Diseases. Excited and Torpid Functional Derangements of the Acoustic Nerve. 
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The External Organs of Generation in the Female. 

Superficial and deeper seated Views of the Muscles of the Male Perineum and Anus. 

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*** The Subjects were selected by Mr. Lawrence, who superintended the Dissections, most 
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